"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"
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.85||||1.85||1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.85||||1.85|0.93|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.85||||1.85|0.72|1.41|0.37
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]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.85||||1.85|1.33|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.85||||1.85|0.93|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.85||||1.85|0.93|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.85||||1.85|1.41|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.85||||1.85|1.28|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.85||||1.85|0.74|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.85||||1.85||1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.85||||1.85|1.28|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.85||||1.85|0.93|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.85||||1.85|1.28|1.41|0.37
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]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.85||||1.85|0|1.41|0.37
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]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.85||||1.85|1.28|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.85||||1.85|0.37|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.85||||1.85|1.28|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.85||||1.85|0.72|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.85||||1.85||1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.85||||1.85||1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.85||||1.85||1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.85||||1.85|1.28|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.85||||1.85|0|1.41|0.37
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]|1.85||||1.85|0|1.41|0.37
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.85||||1.85||1.41|0.37
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.38||||2.38||1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0.93|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|1.71|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|1.19|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.19|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|1.81|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38||1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.38||||2.38|0.48|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.93|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38||1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.38||||2.38||1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38||1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38||1.81|0.48
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14.63||||14.63||11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.63||||14.63|7.32|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.63||||14.63|10.53|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.63||||14.63|7.32|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.63||||14.63|7.32|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.63||||14.63|11.12|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.63||||14.63|5.85|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.63||||14.63||11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.63||||14.63|7.32|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|14.63||||14.63|2.93|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.63||||14.63|5.69|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.63||||14.63||11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14.63||||14.63||11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.63||||14.63||11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.63||||14.63|10.09|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.63||||14.63|0|11.12|2.93
10039|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLAVOXATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.63||||14.63||11.12|2.93
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.39||||12.39||9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.39||||12.39|6.2|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.39||||12.39|4.82|9.42|2.48
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]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.39||||12.39|8.92|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.39||||12.39|6.2|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.39||||12.39|6.2|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.39||||12.39|9.42|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.39||||12.39|8.55|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.39||||12.39|4.96|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.39||||12.39||9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.39||||12.39|8.55|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.39||||12.39|6.2|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.39||||12.39|8.55|9.42|2.48
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]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.39||||12.39|0|9.42|2.48
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]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.39||||12.39|8.55|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|12.39||||12.39|2.48|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.39||||12.39|8.55|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.39||||12.39|4.82|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.39||||12.39||9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.39||||12.39||9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.39||||12.39||9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.39||||12.39|8.55|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.39||||12.39|0|9.42|2.48
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]|12.39||||12.39|0|9.42|2.48
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.39||||12.39||9.42|2.48
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.2||||13.2||10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|5.14|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|9.5|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|6.6|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.6|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|10.03|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2||10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|0|10.03|2.64
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]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|Self-pay|Self-pay|13.2||||13.2|2.64|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.2||||13.2|9.11|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|5.14|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2||10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.2||||13.2||10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2||10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2|0|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2||10.03|2.64
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|818.04||||818.04||621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|818.04||||818.04|409.02|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|818.04||||818.04|588.99|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|818.04||||818.04|409.02|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|818.04||||818.04|409.02|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|818.04||||818.04|621.71|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|818.04||||818.04|327.22|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|818.04||||818.04||621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|818.04||||818.04|409.02|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|Self-pay|Self-pay|818.04||||818.04|163.61|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|818.04||||818.04|318.38|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|818.04||||818.04||621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|818.04||||818.04||621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|818.04||||818.04||621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|818.04||||818.04|564.45|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|818.04||||818.04|0|621.71|163.61
10045|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|818.04||||818.04||621.71|163.61
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|4.32|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|95.04|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|100.32|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|4.32|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|132||||132|26.4|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|51.37|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|66|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132|0|100.32|4.32
10049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|132||||132|66|100.32|4.32
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AARP [1000]|AARP [100000]|2028.69||||2028.69||1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AETNA [1015]|AETNA [101529]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMBETTER [2930]|AMBETTER [293000]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2028.69||||2028.69|1014.35|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2028.69||||2028.69|1460.66|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2028.69||||2028.69|1014.35|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2028.69||||2028.69|1014.35|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2028.69||||2028.69|1541.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|CIGNA [1260]|CIGNA PPO [126025]|2028.69||||2028.69|811.48|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2028.69||||2028.69||1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2028.69||||2028.69|1014.35|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|Self-pay|Self-pay|2028.69||||2028.69|405.74|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|TML [1980]|TML [198000]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2028.69||||2028.69|789.57|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2028.69||||2028.69||1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UNICARE [2040]|UNICARE [204000]|2028.69||||2028.69||1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2028.69||||2028.69||1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WEB TPA [2115]|WEB TPA [211500]|2028.69||||2028.69|1399.8|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2028.69||||2028.69|0|1541.8|405.74
10051|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCYTOSINE 250 MG CAPSULE|2 capsule|WORKER'S COMP [2125]|TML WC [212537]|2028.69||||2028.69||1541.8|405.74
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.15||||11.15||8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.15||||11.15|5.58|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.15||||11.15|4.34|8.47|2.23
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]|11.15||||11.15|0|8.47|2.23
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]|11.15||||11.15|8.03|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.15||||11.15|5.58|8.47|2.23
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]|11.15||||11.15|5.58|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.15||||11.15|8.47|8.47|2.23
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]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.15||||11.15|7.69|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.15||||11.15|4.46|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.15||||11.15||8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.15||||11.15|7.69|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.15||||11.15|5.58|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.15||||11.15|7.69|8.47|2.23
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]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.15||||11.15|0|8.47|2.23
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]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.15||||11.15|7.69|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|11.15||||11.15|2.23|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.15||||11.15|7.69|8.47|2.23
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]|11.15||||11.15|4.34|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.15||||11.15||8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.15||||11.15||8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.15||||11.15||8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.15||||11.15|7.69|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.15||||11.15|0|8.47|2.23
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]|11.15||||11.15|0|8.47|2.23
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.15||||11.15||8.47|2.23
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AARP [1000]|AARP [100000]|198||||198||150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|AETNA [101529]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMBETTER [2930]|AMBETTER [293000]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|99|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|77.06|150.48|39.6
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]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|198||||198|142.56|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|198||||198|99|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|198||||198|99|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|198||||198|150.48|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|198||||198|136.62|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA [1260]|CIGNA PPO [126025]|198||||198|79.2|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198||150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|99|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|150.48|39.6
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]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|0|150.48|39.6
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]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|Self-pay|Self-pay|198||||198|39.6|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TML [1980]|TML [198000]|198||||198|136.62|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|198||||198|77.06|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198||150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNICARE [2040]|UNICARE [204000]|198||||198||150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198||150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198|0|150.48|39.6
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]|198||||198|0|150.48|39.6
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|TML WC [212537]|198||||198||150.48|39.6
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.73||||0.73||0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.73||||0.73|0.37|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.73||||0.73|0.28|0.55|0.15
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]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.53|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.37|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.73||||0.73|0.55|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.73||||0.73|0.5|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|0.73||||0.73|0.29|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.73||||0.73||0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.73||||0.73|0.37|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.73||||0.73|0.5|0.55|0.15
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]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0|0.55|0.15
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]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.73||||0.73|0.15|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|0.73||||0.73|0.5|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.28|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|0.73||||0.73||0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|0.73||||0.73|0.5|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73|0|0.55|0.15
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]|0.73||||0.73|0|0.55|0.15
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|0.73||||0.73||0.55|0.15
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.26||||1.26||0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.26||||1.26|0.63|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.26||||1.26|0.49|0.96|0.25
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]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.26||||1.26|0.91|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.26||||1.26|0.63|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.26||||1.26|0.63|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.26||||1.26|0.96|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.26||||1.26|0.87|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.26||||1.26|0.5|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.26||||1.26||0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.26||||1.26|0.87|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.26||||1.26|0.63|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.26||||1.26|0.87|0.96|0.25
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]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.26||||1.26|0|0.96|0.25
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]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.26||||1.26|0.87|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.26||||1.26|0.25|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.26||||1.26|0.87|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.26||||1.26|0.49|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.26||||1.26||0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.26||||1.26||0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.26||||1.26||0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.26||||1.26|0.87|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.26||||1.26|0|0.96|0.25
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]|1.26||||1.26|0|0.96|0.25
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.26||||1.26||0.96|0.25
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5999.8||||5999.8|355.11|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5999.8||||5999.8|4319.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5999.8||||5999.8|4559.85|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5999.8||||5999.8|355.11|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|5999.8||||5999.8|1199.96|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5999.8||||5999.8|2335.12|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5999.8||||5999.8|2999.9|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|5999.8||||5999.8|4139.86|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5999.8||||5999.8|0|4559.85|355.11
100740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|5999.8||||5999.8|2999.9|4559.85|355.11
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|20.72||||20.72||15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.72||||20.72|10.36|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.72||||20.72|14.92|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.72||||20.72|10.36|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.72||||20.72|10.36|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.72||||20.72|15.75|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20.72||||20.72|8.29|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.72||||20.72||15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.72||||20.72|10.36|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|Self-pay|Self-pay|20.72||||20.72|4.14|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.72||||20.72|8.06|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.72||||20.72||15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|20.72||||20.72||15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.72||||20.72||15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20.72||||20.72|14.3|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.72||||20.72|0|15.75|4.14
10081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTAMIDE 125 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20.72||||20.72||15.75|4.14
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|30.54||||30.54||23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|30.54||||30.54|15.27|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|30.54||||30.54|11.89|23.21|6.11
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]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.54||||30.54|21.99|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.54||||30.54|15.27|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.54||||30.54|15.27|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|30.54||||30.54|23.21|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|30.54||||30.54|21.07|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|30.54||||30.54|12.22|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|30.54||||30.54||23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|30.54||||30.54|21.07|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|30.54||||30.54|15.27|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|30.54||||30.54|21.07|23.21|6.11
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]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.54||||30.54|0|23.21|6.11
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]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|30.54||||30.54|21.07|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|Self-pay|Self-pay|30.54||||30.54|6.11|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|TML [1980]|TML [198000]|30.54||||30.54|21.07|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.54||||30.54|11.89|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.54||||30.54||23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|30.54||||30.54||23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.54||||30.54||23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|30.54||||30.54|21.07|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.54||||30.54|0|23.21|6.11
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]|30.54||||30.54|0|23.21|6.11
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|30.54||||30.54||23.21|6.11
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1123.46||||1123.46|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1123.46||||1123.46|808.89|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1123.46||||1123.46|853.83|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1123.46||||1123.46|449.38|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1123.46||||1123.46|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|1123.46||||1123.46|224.69|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1123.46||||1123.46|437.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|1123.46||||1123.46|775.19|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1123.46||||1123.46|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1123.46||||1123.46|561.73|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1387.32||||1387.32|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1387.32||||1387.32|998.87|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1387.32||||1387.32|1054.36|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1387.32||||1387.32|554.93|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1387.32||||1387.32|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|1387.32||||1387.32|277.46|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1387.32||||1387.32|539.94|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1387.32||||1387.32|957.25|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1387.32||||1387.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1387.32||||1387.32|693.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|391.32||||391.32|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|391.32||||391.32|281.75|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|391.32||||391.32|297.4|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|391.32||||391.32|156.53|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|391.32||||391.32|2.02|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|391.32||||391.32|78.26|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|391.32||||391.32|152.3|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|391.32||||391.32|195.66|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|391.32||||391.32|270.01|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|391.32||||391.32|0|1054.36|2.02
10100|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOTERIDOL 279.3 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|391.32||||391.32|195.66|1054.36|2.02
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48.84||||48.84|2.31|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.84||||48.84|35.16|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48.84||||48.84|37.12|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|48.84||||48.84|19.54|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48.84||||48.84|2.31|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|48.84||||48.84|9.77|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.84||||48.84|19.01|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.84||||48.84|24.42|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|48.84||||48.84|33.7|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.84||||48.84|0|37.12|2.31
10106|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|48.84||||48.84|24.42|37.12|2.31
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18||3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|1.63|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.18||||4.18|3.01|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|2.09|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.18||||4.18|2.09|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|3.18|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18||3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.18||||4.18|1.63|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18||3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18||3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18||3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18||3.18|0.84
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.74||||2.74||2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.74||||2.74|1.37|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.74||||2.74|1.07|2.08|0.55
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]|2.74||||2.74|0|2.08|0.55
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]|2.74||||2.74|1.97|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.74||||2.74|1.37|2.08|0.55
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]|2.74||||2.74|1.37|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.74||||2.74|2.08|2.08|0.55
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]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.74||||2.74|1.89|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.74||||2.74|1.1|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.74||||2.74||2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.74||||2.74|1.89|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.74||||2.74|1.37|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.74||||2.74|1.89|2.08|0.55
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]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.74||||2.74|0|2.08|0.55
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]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.74||||2.74|1.89|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.74||||2.74|0.55|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.74||||2.74|1.89|2.08|0.55
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]|2.74||||2.74|1.07|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.74||||2.74||2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.74||||2.74||2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.74||||2.74||2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.74||||2.74|1.89|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.74||||2.74|0|2.08|0.55
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]|2.74||||2.74|0|2.08|0.55
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.74||||2.74||2.08|0.55
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.7||||2.7||2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.7||||2.7|1.35|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.7||||2.7|1.05|2.05|0.54
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]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.7||||2.7|1.94|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.7||||2.7|1.35|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.7||||2.7|1.35|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.7||||2.7|2.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.7||||2.7|1.86|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.7||||2.7|1.08|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.7||||2.7||2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.7||||2.7|1.86|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.7||||2.7|1.35|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.7||||2.7|1.86|2.05|0.54
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]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.7||||2.7|0|2.05|0.54
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]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.7||||2.7|1.86|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.7||||2.7|0.54|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.7||||2.7|1.86|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.7||||2.7|1.05|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.7||||2.7||2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.7||||2.7||2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.7||||2.7||2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.7||||2.7|1.86|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.7||||2.7|0|2.05|0.54
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]|2.7||||2.7|0|2.05|0.54
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.7||||2.7||2.05|0.54
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.27||||24.27|0.42|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.27||||24.27|17.47|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.27||||24.27|18.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|24.27||||24.27|9.71|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.27||||24.27|0.42|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|24.27||||24.27|4.85|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.27||||24.27|9.45|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|24.27||||24.27|16.75|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.27||||24.27|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|24.27||||24.27|12.14|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101.78||||101.78|0.42|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|73.28|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|101.78||||101.78|77.35|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|101.78||||101.78|70.23|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|101.78||||101.78|40.71|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|70.23|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101.78||||101.78|0.42|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|101.78||||101.78|20.36|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|101.78||||101.78|50.89|77.35|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|43.04||||43.04|0.42|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.04||||43.04|30.99|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|43.04||||43.04|32.71|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|43.04||||43.04|17.22|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|43.04||||43.04|0.42|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|43.04||||43.04|8.61|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.04||||43.04|16.75|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.04||||43.04|21.52|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|43.04||||43.04|29.7|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.04||||43.04|0|32.71|0.42
10177|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|43.04||||43.04|21.52|32.71|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|26.4||||26.4|13.2|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.4||||26.4|0.42|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.4||||26.4|10.27|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|19.01|20.06|0.42
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]|26.4||||26.4|13.2|20.06|0.42
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]|26.4||||26.4|13.2|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.4||||26.4|20.06|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.4||||26.4|18.22|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|26.4||||26.4|10.56|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.4||||26.4|13.2|20.06|0.42
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]|26.4||||26.4|18.22|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.4||||26.4|0.42|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.4||||26.4|18.22|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.4||||26.4|18.22|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|26.4||||26.4|5.28|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|26.4||||26.4|18.22|20.06|0.42
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]|26.4||||26.4|10.27|20.06|0.42
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]|26.4||||26.4|13.2|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|26.4||||26.4|13.2|20.06|0.42
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]|26.4||||26.4|13.2|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|26.4||||26.4|18.22|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
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]|26.4||||26.4|0|20.06|0.42
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|26.4||||26.4|13.2|20.06|0.42
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.2||||7.2||5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.2||||7.2|3.6|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.2||||7.2|2.8|5.47|1.44
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]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.2||||7.2|5.18|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.2||||7.2|3.6|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.2||||7.2|3.6|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.2||||7.2|5.47|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.2||||7.2|4.97|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.2||||7.2|2.88|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.2||||7.2||5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.2||||7.2|4.97|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.2||||7.2|3.6|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.2||||7.2|4.97|5.47|1.44
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]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.2||||7.2|0|5.47|1.44
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]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.2||||7.2|4.97|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|7.2||||7.2|1.44|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.2||||7.2|4.97|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.2||||7.2|2.8|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.2||||7.2||5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.2||||7.2||5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.2||||7.2||5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.2||||7.2|4.97|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.2||||7.2|0|5.47|1.44
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]|7.2||||7.2|0|5.47|1.44
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.2||||7.2||5.47|1.44
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|18.02||||18.02||13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.02||||18.02|9.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.02||||18.02|7.01|13.7|3.6
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]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.02||||18.02|12.97|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.02||||18.02|9.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.02||||18.02|9.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.02||||18.02|13.7|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.02||||18.02|12.43|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|18.02||||18.02|7.21|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.02||||18.02||13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|18.02||||18.02|12.43|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.02||||18.02|9.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.02||||18.02|12.43|13.7|3.6
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]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.02||||18.02|0|13.7|3.6
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]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|18.02||||18.02|12.43|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|18.02||||18.02|3.6|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|18.02||||18.02|12.43|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.02||||18.02|7.01|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.02||||18.02||13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|18.02||||18.02||13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.02||||18.02||13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|18.02||||18.02|12.43|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.02||||18.02|0|13.7|3.6
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]|18.02||||18.02|0|13.7|3.6
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|18.02||||18.02||13.7|3.6
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|9.64||||9.64||7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.64||||9.64|3.75|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.64||||9.64|4.82|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.64||||9.64|3.75|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
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]|9.64||||9.64|6.94|7.33|1.93
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]|9.64||||9.64|4.82|7.33|1.93
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]|9.64||||9.64|4.82|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.64||||9.64|7.33|7.33|1.93
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]|9.64||||9.64|3.75|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.64||||9.64|6.65|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|9.64||||9.64|3.86|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.64||||9.64||7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.64||||9.64|6.65|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.64||||9.64|4.82|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.64||||9.64|6.65|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.64||||9.64|0|7.33|1.93
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]|9.64||||9.64|3.75|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.64||||9.64|0|7.33|1.93
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]|9.64||||9.64|3.75|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.64||||9.64|6.65|7.33|1.93
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]|9.64||||9.64|3.75|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|9.64||||9.64|1.93|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|9.64||||9.64|6.65|7.33|1.93
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]|9.64||||9.64|3.75|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.64||||9.64||7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|9.64||||9.64||7.33|1.93
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]|9.64||||9.64||7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|9.64||||9.64|6.65|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
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]|9.64||||9.64|0|7.33|1.93
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|9.64||||9.64||7.33|1.93
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]|1962.84||||1962.84|981.42|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AMBETTER [2930]|AMBETTER [293000]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1962.84||||1962.84|981.42|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|1413.24|1491.76|117.77
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]|1962.84||||1962.84|981.42|1491.76|117.77
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]|1962.84||||1962.84|981.42|1491.76|117.77
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 TRADITIONAL OF TEXAS [115503]|1962.84||||1962.84|1491.76|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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 - GREAT WEST [126009]|1962.84||||1962.84|1354.36|1491.76|117.77
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 PPO [126025]|1962.84||||1962.84|785.14|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1962.84||||1962.84|981.42|1491.76|117.77
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]|1962.84||||1962.84|1354.36|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1962.84||||1962.84|981.42|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1962.84||||1962.84|1354.36|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|1354.36|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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|1962.84||||1962.84|392.57|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TML [1980]|TML [198000]|1962.84||||1962.84|1354.36|1491.76|117.77
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]|1962.84||||1962.84|763.94|1491.76|117.77
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]|1962.84||||1962.84|981.42|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNICARE [2040]|UNICARE [204000]|1962.84||||1962.84|981.42|1491.76|117.77
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]|1962.84||||1962.84|981.42|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|WEB TPA [2115]|WEB TPA [211500]|1962.84||||1962.84|1354.36|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|1962.84||||1962.84|0|1491.76|117.77
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]|TML WC [212537]|1962.84||||1962.84|981.42|1491.76|117.77
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]|588.86||||588.86|294.43|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|423.98|1491.76|117.77
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]|588.86||||588.86|294.43|1491.76|117.77
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]|588.86||||588.86|294.43|1491.76|117.77
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 TRADITIONAL OF TEXAS [115503]|588.86||||588.86|447.53|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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 - GREAT WEST [126009]|588.86||||588.86|406.31|1491.76|117.77
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 PPO [126025]|588.86||||588.86|235.54|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|294.43|1491.76|117.77
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]|588.86||||588.86|406.31|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|406.31|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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|588.86||||588.86|117.77|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TML [1980]|TML [198000]|588.86||||588.86|406.31|1491.76|117.77
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]|588.86||||588.86|229.18|1491.76|117.77
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]|588.86||||588.86|294.43|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|294.43|1491.76|117.77
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]|588.86||||588.86|294.43|1491.76|117.77
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|588.86||||588.86|0|1491.76|117.77
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]|TML WC [212537]|588.86||||588.86|294.43|1491.76|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|447.53|117.77
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 MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|423.98|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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 TRADITIONAL OF TEXAS [115503]|588.86||||588.86|447.53|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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 - GREAT WEST [126009]|588.86||||588.86|406.31|447.53|117.77
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 PPO [126025]|588.86||||588.86|235.54|447.53|117.77
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|406.31|447.53|117.77
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|447.53|117.77
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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|588.86||||588.86|117.77|447.53|117.77
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|TML [1980]|TML [198000]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|TML WC [212537]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|588.86||||588.86|294.43|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|423.98|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
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 TRADITIONAL OF TEXAS [115503]|588.86||||588.86|447.53|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|588.86||||588.86|406.31|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|588.86||||588.86|235.54|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|406.31|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|588.86||||588.86|294.43|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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|588.86||||588.86|117.77|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TML [1980]|TML [198000]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|229.18|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|588.86||||588.86|294.43|447.53|117.77
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]|588.86||||588.86|294.43|447.53|117.77
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|588.86||||588.86|406.31|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|588.86||||588.86|0|447.53|117.77
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]|TML WC [212537]|588.86||||588.86|294.43|447.53|117.77
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|4.07||||4.07||3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.07||||4.07|2.04|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.07||||4.07|1.58|3.09|0.81
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]|4.07||||4.07|0|3.09|0.81
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]|4.07||||4.07|2.93|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.07||||4.07|2.04|3.09|0.81
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]|4.07||||4.07|2.04|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.07||||4.07|3.09|3.09|0.81
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]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.07||||4.07|2.81|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|4.07||||4.07|1.63|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.07||||4.07||3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|4.07||||4.07|2.81|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.07||||4.07|2.04|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.07||||4.07|2.81|3.09|0.81
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]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.07||||4.07|0|3.09|0.81
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]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|4.07||||4.07|2.81|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|4.07||||4.07|0.81|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|4.07||||4.07|2.81|3.09|0.81
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]|4.07||||4.07|1.58|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.07||||4.07||3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|4.07||||4.07||3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.07||||4.07||3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|4.07||||4.07|2.81|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.07||||4.07|0|3.09|0.81
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]|4.07||||4.07|0|3.09|0.81
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|4.07||||4.07||3.09|0.81
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AARP [1000]|AARP [100000]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1168.73||||1168.73|0.43|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1168.73||||1168.73|841.49|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1168.73||||1168.73|888.23|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1168.73||||1168.73|467.49|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1168.73||||1168.73|0.43|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|Self-pay|Self-pay|1168.73||||1168.73|233.75|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|TML [1980]|TML [198000]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1168.73||||1168.73|454.87|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1168.73||||1168.73|584.37|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1168.73||||1168.73|806.42|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1168.73||||1168.73|0|888.23|0.43
10325|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 41 % INTRATHECAL SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1168.73||||1168.73|584.37|888.23|0.43
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1133.55||||1133.55|0.14|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1133.55||||1133.55|816.16|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1133.55||||1133.55|861.5|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1133.55||||1133.55|453.42|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1133.55||||1133.55|0.14|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|Self-pay|Self-pay|1133.55||||1133.55|226.71|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|TML [1980]|TML [198000]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1133.55||||1133.55|566.78|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|1133.55||||1133.55|782.15|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1133.55||||1133.55|0|861.5|0.14
10327|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRATHECAL SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1133.55||||1133.55|566.78|861.5|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1290.96||||1290.96|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1290.96||||1290.96|0|981.13|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]|1290.96||||1290.96|0|981.13|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]|1290.96||||1290.96|929.49|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1290.96||||1290.96|645.48|981.13|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]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1290.96||||1290.96|981.13|981.13|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]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1290.96||||1290.96|890.76|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1290.96||||1290.96|516.38|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1290.96||||1290.96|890.76|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1290.96||||1290.96|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1290.96||||1290.96|890.76|981.13|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]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1290.96||||1290.96|0|981.13|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]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1290.96||||1290.96|890.76|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1290.96||||1290.96|258.19|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1290.96||||1290.96|890.76|981.13|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]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1290.96||||1290.96|890.76|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1290.96||||1290.96|0|981.13|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]|1290.96||||1290.96|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1290.96||||1290.96|645.48|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.6||||336.6|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.6||||336.6|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.6||||336.6|242.35|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.6||||336.6|242.35|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.6||||336.6|255.82|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.6||||336.6|255.82|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|336.6||||336.6|134.64|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|336.6||||336.6|134.64|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.6||||336.6|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.6||||336.6|0.14|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|336.6||||336.6|67.32|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|336.6||||336.6|67.32|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|336.6||||336.6|232.25|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336.6||||336.6|0|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|336.6||||336.6|168.3|981.13|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|336.6||||336.6|168.3|981.13|0.14
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.71||||6.71||5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.71||||6.71|3.36|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.71||||6.71|2.61|5.1|1.34
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]|6.71||||6.71|0|5.1|1.34
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]|6.71||||6.71|4.83|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.71||||6.71|3.36|5.1|1.34
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]|6.71||||6.71|3.36|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.71||||6.71|5.1|5.1|1.34
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]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.71||||6.71|4.63|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.71||||6.71|2.68|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.71||||6.71||5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.71||||6.71|4.63|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.71||||6.71|3.36|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.71||||6.71|4.63|5.1|1.34
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]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.71||||6.71|0|5.1|1.34
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]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.71||||6.71|4.63|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|6.71||||6.71|1.34|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.71||||6.71|4.63|5.1|1.34
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]|6.71||||6.71|2.61|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.71||||6.71||5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.71||||6.71||5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.71||||6.71||5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.71||||6.71|4.63|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.71||||6.71|0|5.1|1.34
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]|6.71||||6.71|0|5.1|1.34
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.71||||6.71||5.1|1.34
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|44||||44||33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44||||44|22|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44||||44|17.12|33.44|8.8
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]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44||||44|31.68|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44||||44|22|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44||||44|22|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44||||44|33.44|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44||||44|30.36|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|44||||44|17.6|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44||||44||33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|44||||44|30.36|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44||||44|22|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44||||44|30.36|33.44|8.8
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]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44||||44|0|33.44|8.8
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]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|44||||44|30.36|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|44||||44|8.8|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|44||||44|30.36|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44||||44|17.12|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44||||44||33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|44||||44||33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44||||44||33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|44||||44|30.36|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44||||44|0|33.44|8.8
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]|44||||44|0|33.44|8.8
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|44||||44||33.44|8.8
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.98||||5.98||4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.98||||5.98|2.99|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.98||||5.98|2.33|4.54|1.2
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]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.98||||5.98|4.31|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.98||||5.98|2.99|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.98||||5.98|2.99|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.98||||5.98|4.54|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.98||||5.98|4.13|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.98||||5.98|2.39|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.98||||5.98||4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.98||||5.98|4.13|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.98||||5.98|2.99|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.98||||5.98|4.13|4.54|1.2
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]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.98||||5.98|0|4.54|1.2
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]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.98||||5.98|4.13|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|5.98||||5.98|1.2|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.98||||5.98|4.13|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.98||||5.98|2.33|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.98||||5.98||4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.98||||5.98||4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.98||||5.98||4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.98||||5.98|4.13|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.98||||5.98|0|4.54|1.2
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]|5.98||||5.98|0|4.54|1.2
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.98||||5.98||4.54|1.2
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AARP [1000]|AARP [100000]|21.45||||21.45||16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|AETNA [101529]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.45||||21.45|10.73|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.45||||21.45|8.35|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|15.44|16.3|4.29
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]|21.45||||21.45|10.73|16.3|4.29
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]|21.45||||21.45|10.73|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.45||||21.45|16.3|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.45||||21.45|14.8|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|21.45||||21.45|8.58|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.45||||21.45||16.3|4.29
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]|21.45||||21.45|14.8|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.45||||21.45|10.73|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.45||||21.45|14.8|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.45||||21.45|14.8|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|Self-pay|Self-pay|21.45||||21.45|4.29|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TML [1980]|TML [198000]|21.45||||21.45|14.8|16.3|4.29
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]|21.45||||21.45|8.35|16.3|4.29
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]|21.45||||21.45||16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|21.45||||21.45||16.3|4.29
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]|21.45||||21.45||16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|21.45||||21.45|14.8|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
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]|21.45||||21.45|0|16.3|4.29
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|21.45||||21.45||16.3|4.29
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AARP [1000]|AARP [100000]|52.67||||52.67||40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AETNA [1015]|AETNA [101529]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMBETTER [2930]|AMBETTER [293000]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.67||||52.67|26.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.67||||52.67|37.92|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.67||||52.67|26.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.67||||52.67|26.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.67||||52.67|40.03|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|CIGNA [1260]|CIGNA PPO [126025]|52.67||||52.67|21.07|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.67||||52.67||40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.67||||52.67|26.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|Self-pay|Self-pay|52.67||||52.67|10.53|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|TML [1980]|TML [198000]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.67||||52.67|20.5|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.67||||52.67||40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UNICARE [2040]|UNICARE [204000]|52.67||||52.67||40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.67||||52.67||40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WEB TPA [2115]|WEB TPA [211500]|52.67||||52.67|36.34|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.67||||52.67|0|40.03|10.53
103884|ERX|0250 - PHARMACY-GENERAL|CAMPHOR 4 %-METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM|57 g|WORKER'S COMP [2125]|TML WC [212537]|52.67||||52.67||40.03|10.53
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.59||||7.59||5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.59||||7.59|3.8|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.59||||7.59|2.95|5.77|1.52
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]|7.59||||7.59|0|5.77|1.52
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]|7.59||||7.59|5.46|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.59||||7.59|3.8|5.77|1.52
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]|7.59||||7.59|3.8|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.59||||7.59|5.77|5.77|1.52
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]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.59||||7.59|5.24|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.59||||7.59|3.04|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.59||||7.59||5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.59||||7.59|5.24|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.59||||7.59|3.8|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.59||||7.59|5.24|5.77|1.52
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]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.59||||7.59|0|5.77|1.52
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]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.59||||7.59|5.24|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.59||||7.59|1.52|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.59||||7.59|5.24|5.77|1.52
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]|7.59||||7.59|2.95|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.59||||7.59||5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.59||||7.59||5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.59||||7.59||5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.59||||7.59|5.24|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.59||||7.59|0|5.77|1.52
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]|7.59||||7.59|0|5.77|1.52
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.59||||7.59||5.77|1.52
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.14||||6.14||4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.14||||6.14|3.07|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.14||||6.14|2.39|4.67|1.23
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]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.14||||6.14|4.42|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.14||||6.14|3.07|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.14||||6.14|3.07|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.14||||6.14|4.67|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.14||||6.14|4.24|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.14||||6.14|2.46|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.14||||6.14||4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.14||||6.14|4.24|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.14||||6.14|3.07|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.14||||6.14|4.24|4.67|1.23
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]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.14||||6.14|0|4.67|1.23
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]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.14||||6.14|4.24|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|Self-pay|Self-pay|6.14||||6.14|1.23|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TML [1980]|TML [198000]|6.14||||6.14|4.24|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.14||||6.14|2.39|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.14||||6.14||4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.14||||6.14||4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.14||||6.14||4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.14||||6.14|4.24|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.14||||6.14|0|4.67|1.23
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]|6.14||||6.14|0|4.67|1.23
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.14||||6.14||4.67|1.23
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.15||||7.15||5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.15||||7.15|3.58|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.15||||7.15|2.78|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.15||||7.15|5.15|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.15||||7.15|3.58|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.15||||7.15|3.58|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.15||||7.15|5.43|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.15||||7.15|4.93|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.15||||7.15|2.86|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.15||||7.15||5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.15||||7.15|4.93|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.15||||7.15|3.58|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.15||||7.15|4.93|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.15||||7.15|0|5.43|1.43
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]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.15||||7.15|4.93|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|Self-pay|Self-pay|7.15||||7.15|1.43|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TML [1980]|TML [198000]|7.15||||7.15|4.93|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.15||||7.15|2.78|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.15||||7.15||5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.15||||7.15||5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.15||||7.15||5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.15||||7.15|4.93|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.15||||7.15|0|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.15||||7.15||5.43|1.43
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|39.6||||39.6||30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|28.51|30.1|7.92
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]|39.6||||39.6|19.8|30.1|7.92
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]|39.6||||39.6|19.8|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||30.1|7.92
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]|39.6||||39.6||30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||30.1|7.92
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.43||||0.43||0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.43||||0.43|0.22|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.43||||0.43|0.17|0.33|0.09
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]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.43||||0.43|0.31|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.43||||0.43|0.22|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.43||||0.43|0.22|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.43||||0.43|0.33|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.43||||0.43|0.3|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.43||||0.43||0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.43||||0.43|0.3|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.43||||0.43|0.22|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.43||||0.43|0.3|0.33|0.09
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]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.43||||0.43|0|0.33|0.09
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]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.43||||0.43|0.3|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.43||||0.43|0.09|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.43||||0.43|0.3|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.43||||0.43|0.17|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.43||||0.43||0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.43||||0.43||0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.43||||0.43||0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.43||||0.43|0.3|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.43||||0.43|0|0.33|0.09
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]|0.43||||0.43|0|0.33|0.09
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.43||||0.43||0.33|0.09
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AARP [1000]|AARP [100000]|303.33||||303.33||230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|AETNA [101529]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMBETTER [2930]|AMBETTER [293000]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|303.33||||303.33|151.67|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|303.33||||303.33|118.06|230.53|60.67
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]|303.33||||303.33|0|230.53|60.67
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]|303.33||||303.33|218.4|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.33||||303.33|151.67|230.53|60.67
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]|303.33||||303.33|151.67|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|303.33||||303.33|230.53|230.53|60.67
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]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|303.33||||303.33|209.3|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA PPO [126025]|303.33||||303.33|121.33|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|303.33||||303.33||230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|303.33||||303.33|209.3|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|303.33||||303.33|151.67|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|303.33||||303.33|209.3|230.53|60.67
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]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.33||||303.33|0|230.53|60.67
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]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|303.33||||303.33|209.3|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|Self-pay|Self-pay|303.33||||303.33|60.67|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TML [1980]|TML [198000]|303.33||||303.33|209.3|230.53|60.67
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]|303.33||||303.33|118.06|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.33||||303.33||230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNICARE [2040]|UNICARE [204000]|303.33||||303.33||230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.33||||303.33||230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WEB TPA [2115]|WEB TPA [211500]|303.33||||303.33|209.3|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.33||||303.33|0|230.53|60.67
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]|303.33||||303.33|0|230.53|60.67
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TML WC [212537]|303.33||||303.33||230.53|60.67
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|42.9||||42.9|21.45|32.6|0.94
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]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.9||||42.9|16.7|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|42.9||||42.9|0.94|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|42.9||||42.9|16.7|32.6|0.94
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]|42.9||||42.9|0|32.6|0.94
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]|42.9||||42.9|30.89|32.6|0.94
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]|42.9||||42.9|21.45|32.6|0.94
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]|42.9||||42.9|21.45|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|42.9||||42.9|32.6|32.6|0.94
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]|42.9||||42.9|16.7|32.6|0.94
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]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|42.9||||42.9|29.6|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|42.9||||42.9|17.16|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|42.9||||42.9|21.45|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|42.9||||42.9|29.6|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|42.9||||42.9|0.94|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|42.9||||42.9|29.6|32.6|0.94
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]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.9||||42.9|16.7|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.9||||42.9|0|32.6|0.94
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]|42.9||||42.9|16.7|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|42.9||||42.9|29.6|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.9||||42.9|16.7|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|42.9||||42.9|8.58|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|42.9||||42.9|29.6|32.6|0.94
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]|42.9||||42.9|16.7|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.9||||42.9|21.45|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|42.9||||42.9|21.45|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.9||||42.9|21.45|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|42.9||||42.9|29.6|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.9||||42.9|0|32.6|0.94
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]|42.9||||42.9|0|32.6|0.94
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|42.9||||42.9|21.45|32.6|0.94
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AARP [1000]|AARP [100000]|80.16||||80.16||60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AETNA [1015]|AETNA [101529]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMBETTER [2930]|AMBETTER [293000]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80.16||||80.16|40.08|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80.16||||80.16|57.72|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80.16||||80.16|40.08|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80.16||||80.16|40.08|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80.16||||80.16|60.92|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|CIGNA [1260]|CIGNA PPO [126025]|80.16||||80.16|32.06|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80.16||||80.16||60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80.16||||80.16|40.08|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|Self-pay|Self-pay|80.16||||80.16|16.03|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|TML [1980]|TML [198000]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80.16||||80.16|31.2|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80.16||||80.16||60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UNICARE [2040]|UNICARE [204000]|80.16||||80.16||60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80.16||||80.16||60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WEB TPA [2115]|WEB TPA [211500]|80.16||||80.16|55.31|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80.16||||80.16|0|60.92|16.03
10533|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 250 MG CAPSULE,CONTROLLED RELEASE|2 capsule|WORKER'S COMP [2125]|TML WC [212537]|80.16||||80.16||60.92|16.03
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AARP [1000]|AARP [100000]|176.62||||176.62||134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AETNA [1015]|AETNA [101529]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AMBETTER [2930]|AMBETTER [293000]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|176.62||||176.62|88.31|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|176.62||||176.62|127.17|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|176.62||||176.62|88.31|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|176.62||||176.62|88.31|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|176.62||||176.62|134.23|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|CIGNA [1260]|CIGNA PPO [126025]|176.62||||176.62|70.65|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|176.62||||176.62||134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|176.62||||176.62|88.31|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|Self-pay|Self-pay|176.62||||176.62|35.32|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|TML [1980]|TML [198000]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|176.62||||176.62|68.74|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|176.62||||176.62||134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNICARE [2040]|UNICARE [204000]|176.62||||176.62||134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|176.62||||176.62||134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WEB TPA [2115]|WEB TPA [211500]|176.62||||176.62|121.87|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|176.62||||176.62|0|134.23|35.32
10535|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 4 GRAM/60 ML ENEMA|60 mL|WORKER'S COMP [2125]|TML WC [212537]|176.62||||176.62||134.23|35.32
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AARP [1000]|AARP [100000]|2866.52||||2866.52||2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AETNA [1015]|AETNA [101529]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2866.52||||2866.52|1433.26|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2866.52||||2866.52|2063.89|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2866.52||||2866.52|1433.26|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2866.52||||2866.52|1433.26|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2866.52||||2866.52|2178.56|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|2866.52||||2866.52|1146.61|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2866.52||||2866.52||2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2866.52||||2866.52|1433.26|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|Self-pay|Self-pay|2866.52||||2866.52|573.3|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|TML [1980]|TML [198000]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2866.52||||2866.52|1115.65|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2866.52||||2866.52||2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|UNICARE [2040]|UNICARE [204000]|2866.52||||2866.52||2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2866.52||||2866.52||2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|2866.52||||2866.52|1977.9|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2866.52||||2866.52|0|2178.56|573.3
105410|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BIMATOPROST 0.01 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|2866.52||||2866.52||2178.56|573.3
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.53||||0.53|0.27|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.53||||0.53|0.21|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.38|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.27|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.53||||0.53|0.4|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.53||||0.53|0.37|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.53||||0.53||0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.53||||0.53|0.27|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.53||||0.53|0.37|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.11|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.53||||0.53|0.37|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.21|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.53||||0.53||0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.53||||0.53|0.37|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.53||||0.53||0.4|0.11
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.69||||3.69||2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.69||||3.69|1.85|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.69||||3.69|2.66|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.69||||3.69|1.85|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.69||||3.69|1.85|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.69||||3.69|2.8|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.69||||3.69|1.48|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.69||||3.69||2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.69||||3.69|1.85|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|Self-pay|Self-pay|3.69||||3.69|0.74|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.69||||3.69|1.44|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.69||||3.69||2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.69||||3.69||2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.69||||3.69||2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.69||||3.69|2.55|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.69||||3.69|0|2.8|0.74
10553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.69||||3.69||2.8|0.74
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|63.76||||63.76||48.46|12.75
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]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.76||||63.76|24.82|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|63.76||||63.76|31.88|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|63.76||||63.76|24.82|48.46|12.75
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]|63.76||||63.76|0|48.46|12.75
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]|63.76||||63.76|45.91|48.46|12.75
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]|63.76||||63.76|31.88|48.46|12.75
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]|63.76||||63.76|31.88|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|63.76||||63.76|48.46|48.46|12.75
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]|63.76||||63.76|24.82|48.46|12.75
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]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|63.76||||63.76|43.99|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|63.76||||63.76|25.5|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|63.76||||63.76||48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|63.76||||63.76|43.99|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|63.76||||63.76|31.88|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.76||||63.76|43.99|48.46|12.75
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]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.76||||63.76|24.82|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.76||||63.76|0|48.46|12.75
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]|63.76||||63.76|24.82|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|63.76||||63.76|43.99|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.76||||63.76|24.82|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|Self-pay|Self-pay|63.76||||63.76|12.75|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|63.76||||63.76|43.99|48.46|12.75
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]|63.76||||63.76|24.82|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.76||||63.76||48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|63.76||||63.76||48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.76||||63.76||48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|63.76||||63.76|43.99|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.76||||63.76|0|48.46|12.75
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]|63.76||||63.76|0|48.46|12.75
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|63.76||||63.76||48.46|12.75
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|31.55||||31.55|15.78|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|31.55||||31.55|12.28|23.98|4.83
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]|31.55||||31.55|0|23.98|4.83
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]|31.55||||31.55|22.72|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.55||||31.55|15.78|23.98|4.83
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]|31.55||||31.55|15.78|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|31.55||||31.55|23.98|23.98|4.83
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]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|31.55||||31.55|21.77|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|31.55||||31.55|12.62|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.55||||31.55|21.77|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|31.55||||31.55|15.78|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|31.55||||31.55|21.77|23.98|4.83
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]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.55||||31.55|0|23.98|4.83
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]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.55||||31.55|21.77|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|31.55||||31.55|6.31|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|31.55||||31.55|21.77|23.98|4.83
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]|31.55||||31.55|12.28|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|31.55||||31.55|21.77|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.55||||31.55|0|23.98|4.83
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]|31.55||||31.55|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|31.55||||31.55||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|24.16||||24.16||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.16||||24.16|12.08|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.16||||24.16|9.4|23.98|4.83
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]|24.16||||24.16|0|23.98|4.83
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]|24.16||||24.16|17.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.16||||24.16|12.08|23.98|4.83
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]|24.16||||24.16|12.08|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.16||||24.16|18.36|23.98|4.83
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]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.16||||24.16|16.67|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|24.16||||24.16|9.66|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.16||||24.16||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.16||||24.16|16.67|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.16||||24.16|12.08|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.16||||24.16|16.67|23.98|4.83
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]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.16||||24.16|0|23.98|4.83
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]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.16||||24.16|16.67|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|Self-pay|Self-pay|24.16||||24.16|4.83|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|24.16||||24.16|16.67|23.98|4.83
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]|24.16||||24.16|9.4|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.16||||24.16||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|24.16||||24.16||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.16||||24.16||23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|24.16||||24.16|16.67|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.16||||24.16|0|23.98|4.83
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]|24.16||||24.16|0|23.98|4.83
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|24.16||||24.16||23.98|4.83
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|372.24||||372.24||282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|372.24||||372.24|25.1|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|372.24||||372.24|268.01|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|372.24||||372.24|186.12|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|372.24||||372.24|186.12|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|372.24||||372.24|282.9|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|372.24||||372.24|148.9|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|372.24||||372.24||282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|372.24||||372.24|25.1|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|Self-pay|Self-pay|372.24||||372.24|74.45|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|372.24||||372.24|144.88|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|372.24||||372.24||282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|372.24||||372.24||282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|372.24||||372.24||282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|372.24||||372.24|256.85|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|372.24||||372.24|0|282.9|25.1
10571|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|372.24||||372.24||282.9|25.1
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.1||||1.1||0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.1||||1.1|0.55|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0.79|0.84|0.22
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]|1.1||||1.1|0.55|0.84|0.22
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]|1.1||||1.1|0.55|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.1||||1.1|0.84|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.1||||1.1|0.76|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.1||||1.1|0.44|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.1||||1.1||0.84|0.22
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]|1.1||||1.1|0.76|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.1||||1.1|0.55|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.1||||1.1|0.76|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1|0.76|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|1.1||||1.1|0.22|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|1.1||||1.1|0.76|0.84|0.22
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]|1.1||||1.1|0.43|0.84|0.22
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]|1.1||||1.1||0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|1.1||||1.1||0.84|0.22
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]|1.1||||1.1||0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.1||||1.1|0.76|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
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]|1.1||||1.1|0|0.84|0.22
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.1||||1.1||0.84|0.22
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AARP [1000]|AARP [100000]|580.54||||580.54|290.27|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|AETNA [101529]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.54||||580.54|7.14|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|417.99|441.21|7.14
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]|580.54||||580.54|290.27|441.21|7.14
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]|580.54||||580.54|290.27|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.54||||580.54|441.21|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.54||||580.54|400.57|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|580.54||||580.54|232.22|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.54||||580.54|290.27|441.21|7.14
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]|580.54||||580.54|400.57|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.54||||580.54|7.14|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.54||||580.54|400.57|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|400.57|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|Self-pay|Self-pay|580.54||||580.54|116.11|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TML [1980]|TML [198000]|580.54||||580.54|400.57|441.21|7.14
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]|580.54||||580.54|225.95|441.21|7.14
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]|580.54||||580.54|290.27|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|580.54||||580.54|290.27|441.21|7.14
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]|580.54||||580.54|290.27|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|580.54||||580.54|400.57|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
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]|580.54||||580.54|0|441.21|7.14
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|580.54||||580.54|290.27|441.21|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|153.78||||153.78|7.14|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|153.78||||153.78|110.72|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|153.78||||153.78|116.87|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|153.78||||153.78|61.51|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|153.78||||153.78|7.14|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|153.78||||153.78|30.76|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|TML [1980]|TML [198000]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|153.78||||153.78|59.85|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNICARE [2040]|UNICARE [204000]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|153.78||||153.78|76.89|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|153.78||||153.78|106.11|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|153.78||||153.78|0|116.87|7.14
10578|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|153.78||||153.78|76.89|116.87|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AARP [1000]|AARP [100000]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AETNA [1015]|AETNA [101529]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AMBETTER [2930]|AMBETTER [293000]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1151.97||||1151.97|7.14|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1151.97||||1151.97|829.42|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1151.97||||1151.97|875.5|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|CIGNA [1260]|CIGNA PPO [126025]|1151.97||||1151.97|460.79|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1151.97||||1151.97|7.14|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|Self-pay|Self-pay|1151.97||||1151.97|230.39|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|TML [1980]|TML [198000]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1151.97||||1151.97|448.35|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|UNICARE [2040]|UNICARE [204000]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1151.97||||1151.97|575.99|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|WEB TPA [2115]|WEB TPA [211500]|1151.97||||1151.97|794.86|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1151.97||||1151.97|0|875.5|7.14
10579|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 2 GRAM INTRAVENOUS SOLUTION|2,000 mg|WORKER'S COMP [2125]|TML WC [212537]|1151.97||||1151.97|575.99|875.5|7.14
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|80.26||||80.26|40.13|61|5.69
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]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|31.24|61|5.69
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]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80.26||||80.26|5.69|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80.26||||80.26|31.24|61|5.69
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]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|57.79|61|5.69
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]|80.26||||80.26|40.13|61|5.69
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]|80.26||||80.26|40.13|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80.26||||80.26|61|61|5.69
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]|80.26||||80.26|31.24|61|5.69
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]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80.26||||80.26|55.38|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|80.26||||80.26|32.1|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80.26||||80.26|40.13|61|5.69
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]|80.26||||80.26|55.38|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80.26||||80.26|5.69|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80.26||||80.26|55.38|61|5.69
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]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|31.24|61|5.69
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]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|31.24|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|80.26||||80.26|55.38|61|5.69
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]|80.26||||80.26|31.24|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|Self-pay|Self-pay|80.26||||80.26|16.05|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|TML [1980]|TML [198000]|80.26||||80.26|55.38|61|5.69
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]|80.26||||80.26|31.24|61|5.69
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]|80.26||||80.26|40.13|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|80.26||||80.26|40.13|61|5.69
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]|80.26||||80.26|40.13|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|80.26||||80.26|55.38|61|5.69
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]|80.26||||80.26|0|61|5.69
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]|80.26||||80.26|0|61|5.69
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|80.26||||80.26|40.13|61|5.69
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|320.5||||320.5|160.25|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320.5||||320.5|124.74|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|320.5||||320.5|7.14|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|320.5||||320.5|124.74|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
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]|320.5||||320.5|230.76|243.58|7.14
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]|320.5||||320.5|160.25|243.58|7.14
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]|320.5||||320.5|160.25|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|320.5||||320.5|243.58|243.58|7.14
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]|320.5||||320.5|124.74|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|320.5||||320.5|221.15|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|320.5||||320.5|128.2|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|320.5||||320.5|160.25|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|320.5||||320.5|221.15|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|320.5||||320.5|7.14|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|320.5||||320.5|221.15|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320.5||||320.5|0|243.58|7.14
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]|320.5||||320.5|124.74|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320.5||||320.5|0|243.58|7.14
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]|320.5||||320.5|124.74|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|320.5||||320.5|221.15|243.58|7.14
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]|320.5||||320.5|124.74|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|320.5||||320.5|64.1|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|320.5||||320.5|221.15|243.58|7.14
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]|320.5||||320.5|124.74|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320.5||||320.5|160.25|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|320.5||||320.5|160.25|243.58|7.14
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]|320.5||||320.5|160.25|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|320.5||||320.5|221.15|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
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]|320.5||||320.5|0|243.58|7.14
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|320.5||||320.5|160.25|243.58|7.14
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AARP [1000]|AARP [100000]|436.61||||436.61|218.31|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA [1015]|AETNA [101529]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AMBETTER [2930]|AMBETTER [293000]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|436.61||||436.61|1.04|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|314.36|331.82|1.04
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]|436.61||||436.61|218.31|331.82|1.04
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]|436.61||||436.61|218.31|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|436.61||||436.61|331.82|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|436.61||||436.61|301.26|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA [1260]|CIGNA PPO [126025]|436.61||||436.61|174.64|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|436.61||||436.61|218.31|331.82|1.04
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]|436.61||||436.61|301.26|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|436.61||||436.61|1.04|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|436.61||||436.61|301.26|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|301.26|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|Self-pay|Self-pay|436.61||||436.61|87.32|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TML [1980]|TML [198000]|436.61||||436.61|301.26|331.82|1.04
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]|436.61||||436.61|169.93|331.82|1.04
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]|436.61||||436.61|218.31|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNICARE [2040]|UNICARE [204000]|436.61||||436.61|218.31|331.82|1.04
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]|436.61||||436.61|218.31|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WEB TPA [2115]|WEB TPA [211500]|436.61||||436.61|301.26|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
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]|436.61||||436.61|0|331.82|1.04
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WORKER'S COMP [2125]|TML WC [212537]|436.61||||436.61|218.31|331.82|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|157.48||||157.48|1.04|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|157.48||||157.48|113.39|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|157.48||||157.48|119.68|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|157.48||||157.48|62.99|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|157.48||||157.48|1.04|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|Self-pay|Self-pay|157.48||||157.48|31.5|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TML [1980]|TML [198000]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|157.48||||157.48|61.29|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNICARE [2040]|UNICARE [204000]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|157.48||||157.48|78.74|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|157.48||||157.48|108.66|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|157.48||||157.48|0|119.68|1.04
105901|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|157.48||||157.48|78.74|119.68|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|874.26||||874.26|437.13|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|874.26||||874.26|1.04|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|629.47|664.44|1.04
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]|874.26||||874.26|437.13|664.44|1.04
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]|874.26||||874.26|437.13|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|874.26||||874.26|664.44|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|874.26||||874.26|603.24|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|874.26||||874.26|349.7|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|874.26||||874.26|437.13|664.44|1.04
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]|874.26||||874.26|603.24|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|874.26||||874.26|1.04|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|874.26||||874.26|603.24|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|603.24|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|874.26||||874.26|174.85|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|874.26||||874.26|603.24|664.44|1.04
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]|874.26||||874.26|340.26|664.44|1.04
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]|874.26||||874.26|437.13|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|874.26||||874.26|437.13|664.44|1.04
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]|874.26||||874.26|437.13|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|874.26||||874.26|603.24|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
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]|874.26||||874.26|0|664.44|1.04
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|874.26||||874.26|437.13|664.44|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|580.8||||580.8|290.4|441.41|1.04
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]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMBETTER [2930]|AMBETTER [293000]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.8||||580.8|226.05|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.8||||580.8|1.04|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.8||||580.8|226.05|441.41|1.04
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]|580.8||||580.8|0|441.41|1.04
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]|580.8||||580.8|418.18|441.41|1.04
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]|580.8||||580.8|290.4|441.41|1.04
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]|580.8||||580.8|290.4|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.8||||580.8|441.41|441.41|1.04
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]|580.8||||580.8|226.05|441.41|1.04
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]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.8||||580.8|400.75|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA PPO [126025]|580.8||||580.8|232.32|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.8||||580.8|290.4|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|580.8||||580.8|400.75|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.8||||580.8|1.04|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.8||||580.8|400.75|441.41|1.04
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]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.8||||580.8|226.05|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.8||||580.8|0|441.41|1.04
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]|580.8||||580.8|226.05|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|580.8||||580.8|400.75|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.8||||580.8|226.05|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|580.8||||580.8|116.16|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TML [1980]|TML [198000]|580.8||||580.8|400.75|441.41|1.04
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]|580.8||||580.8|226.05|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.8||||580.8|290.4|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNICARE [2040]|UNICARE [204000]|580.8||||580.8|290.4|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.8||||580.8|290.4|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WEB TPA [2115]|WEB TPA [211500]|580.8||||580.8|400.75|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.8||||580.8|0|441.41|1.04
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]|580.8||||580.8|0|441.41|1.04
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TML WC [212537]|580.8||||580.8|290.4|441.41|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1311.78||||1311.78|1.04|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1311.78||||1311.78|944.48|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1311.78||||1311.78|996.95|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|1311.78||||1311.78|524.71|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1311.78||||1311.78|1.04|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|1311.78||||1311.78|262.36|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1311.78||||1311.78|510.54|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1311.78||||1311.78|655.89|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|1311.78||||1311.78|905.13|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1311.78||||1311.78|0|996.95|1.04
105904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|1311.78||||1311.78|655.89|996.95|1.04
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|39.79||||39.79||30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.79||||39.79|19.9|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.79||||39.79|15.49|30.24|7.96
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]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.79||||39.79|28.65|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.79||||39.79|19.9|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.79||||39.79|19.9|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.79||||39.79|30.24|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.79||||39.79|27.46|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|39.79||||39.79|15.92|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.79||||39.79||30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|39.79||||39.79|27.46|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.79||||39.79|19.9|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.79||||39.79|27.46|30.24|7.96
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]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.79||||39.79|0|30.24|7.96
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]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|39.79||||39.79|27.46|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|39.79||||39.79|7.96|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|39.79||||39.79|27.46|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.79||||39.79|15.49|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.79||||39.79||30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|39.79||||39.79||30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.79||||39.79||30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|39.79||||39.79|27.46|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.79||||39.79|0|30.24|7.96
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]|39.79||||39.79|0|30.24|7.96
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|39.79||||39.79||30.24|7.96
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AARP [1000]|AARP [100000]|324.91||||324.91||246.93|9.3
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]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMBETTER [2930]|AMBETTER [293000]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324.91||||324.91|126.45|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|324.91||||324.91|9.3|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|324.91||||324.91|126.45|246.93|9.3
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]|324.91||||324.91|0|246.93|9.3
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]|324.91||||324.91|233.94|246.93|9.3
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]|324.91||||324.91|162.46|246.93|9.3
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]|324.91||||324.91|162.46|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|324.91||||324.91|246.93|246.93|9.3
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]|324.91||||324.91|126.45|246.93|9.3
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]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|324.91||||324.91|224.19|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA PPO [126025]|324.91||||324.91|129.96|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|324.91||||324.91||246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|324.91||||324.91|224.19|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|324.91||||324.91|9.3|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|324.91||||324.91|224.19|246.93|9.3
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]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324.91||||324.91|126.45|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324.91||||324.91|0|246.93|9.3
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]|324.91||||324.91|126.45|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|324.91||||324.91|224.19|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324.91||||324.91|126.45|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|Self-pay|Self-pay|324.91||||324.91|64.98|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TML [1980]|TML [198000]|324.91||||324.91|224.19|246.93|9.3
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]|324.91||||324.91|126.45|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324.91||||324.91||246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNICARE [2040]|UNICARE [204000]|324.91||||324.91||246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324.91||||324.91||246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WEB TPA [2115]|WEB TPA [211500]|324.91||||324.91|224.19|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324.91||||324.91|0|246.93|9.3
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]|324.91||||324.91|0|246.93|9.3
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TML WC [212537]|324.91||||324.91||246.93|9.3
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]|11.88||||11.88|5.94|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMBETTER [2930]|AMBETTER [293000]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.88||||11.88|0.12|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|8.55|9.03|0.12
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]|11.88||||11.88|5.94|9.03|0.12
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]|11.88||||11.88|5.94|9.03|0.12
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 TRADITIONAL OF TEXAS [115503]|11.88||||11.88|9.03|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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 - GREAT WEST [126009]|11.88||||11.88|8.2|9.03|0.12
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 PPO [126025]|11.88||||11.88|4.75|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.88||||11.88|5.94|9.03|0.12
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]|11.88||||11.88|8.2|9.03|0.12
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.88||||11.88|0.12|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.88||||11.88|8.2|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|8.2|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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|11.88||||11.88|2.38|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TML [1980]|TML [198000]|11.88||||11.88|8.2|9.03|0.12
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]|11.88||||11.88|4.62|9.03|0.12
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]|11.88||||11.88|5.94|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNICARE [2040]|UNICARE [204000]|11.88||||11.88|5.94|9.03|0.12
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]|11.88||||11.88|5.94|9.03|0.12
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WEB TPA [2115]|WEB TPA [211500]|11.88||||11.88|8.2|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|11.88||||11.88|0|9.03|0.12
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]|TML WC [212537]|11.88||||11.88|5.94|9.03|0.12
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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|AMBETTER [2930]|AMBETTER [293000]|15.78||||15.78|0|11.99|3.16
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|AMBETTER [2930]|AMBETTER [293000]|15.78||||15.78|0|11.99|3.16
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|AMBETTER [2930]|AMBETTER [293000]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.78||||15.78|7.89|11.99|3.16
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.78||||15.78|7.89|11.99|3.16
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.78||||15.78|7.89|11.99|3.16
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 MEDICAID [1165]|BCBS MEDICAID [116504]|15.78||||15.78|6.14|11.99|3.16
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 MEDICAID [1165]|BCBS MEDICAID [116504]|15.78||||15.78|6.14|11.99|3.16
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 MEDICAID [1165]|BCBS MEDICAID [116504]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|11.36|11.99|3.16
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]|15.78||||15.78|11.36|11.99|3.16
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]|15.78||||15.78|11.36|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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]|15.78||||15.78|7.89|11.99|3.16
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 TRADITIONAL OF TEXAS [115503]|15.78||||15.78|11.99|11.99|3.16
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 TRADITIONAL OF TEXAS [115503]|15.78||||15.78|11.99|11.99|3.16
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 TRADITIONAL OF TEXAS [115503]|15.78||||15.78|11.99|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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 - GREAT WEST [126009]|15.78||||15.78|10.89|11.99|3.16
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 - GREAT WEST [126009]|15.78||||15.78|10.89|11.99|3.16
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 - GREAT WEST [126009]|15.78||||15.78|10.89|11.99|3.16
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 PPO [126025]|15.78||||15.78|6.31|11.99|3.16
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 PPO [126025]|15.78||||15.78|6.31|11.99|3.16
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 PPO [126025]|15.78||||15.78|6.31|11.99|3.16
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.78||||15.78||11.99|3.16
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.78||||15.78||11.99|3.16
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.78||||15.78|7.89|11.99|3.16
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.78||||15.78|7.89|11.99|3.16
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.78||||15.78|7.89|11.99|3.16
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.78||||15.78|10.89|11.99|3.16
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.78||||15.78|10.89|11.99|3.16
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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|15.78||||15.78|3.16|11.99|3.16
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|15.78||||15.78|3.16|11.99|3.16
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|15.78||||15.78|3.16|11.99|3.16
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|TML [1980]|TML [198000]|15.78||||15.78|10.89|11.99|3.16
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|TML [1980]|TML [198000]|15.78||||15.78|10.89|11.99|3.16
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|TML [1980]|TML [198000]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78|6.14|11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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|UNICARE [2040]|UNICARE [204000]|15.78||||15.78||11.99|3.16
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|UNICARE [2040]|UNICARE [204000]|15.78||||15.78||11.99|3.16
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|UNICARE [2040]|UNICARE [204000]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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]|15.78||||15.78||11.99|3.16
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|WEB TPA [2115]|WEB TPA [211500]|15.78||||15.78|10.89|11.99|3.16
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|WEB TPA [2115]|WEB TPA [211500]|15.78||||15.78|10.89|11.99|3.16
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|WEB TPA [2115]|WEB TPA [211500]|15.78||||15.78|10.89|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|15.78||||15.78|0|11.99|3.16
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]|TML WC [212537]|15.78||||15.78||11.99|3.16
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]|TML WC [212537]|15.78||||15.78||11.99|3.16
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]|TML WC [212537]|15.78||||15.78||11.99|3.16
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]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.63||||3.63|1.82|2.76|0.73
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 MEDICAID [1165]|BCBS MEDICAID [116504]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|2.61|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
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 TRADITIONAL OF TEXAS [115503]|3.63||||3.63|2.76|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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 - GREAT WEST [126009]|3.63||||3.63|2.5|2.76|0.73
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 PPO [126025]|3.63||||3.63|1.45|2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63|2.5|2.76|0.73
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.63||||3.63|1.82|2.76|0.73
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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|3.63||||3.63|0.73|2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|TML [1980]|TML [198000]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63||2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNICARE [2040]|UNICARE [204000]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63||2.76|0.73
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|TML WC [212537]|3.63||||3.63||2.76|0.73
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AARP [1000]|AARP [100000]|423.12||||423.12||321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|AETNA [101529]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMBETTER [2930]|AMBETTER [293000]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|423.12||||423.12|211.56|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|423.12||||423.12|164.68|321.57|84.62
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]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|423.12||||423.12|304.65|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|423.12||||423.12|211.56|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|423.12||||423.12|211.56|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|423.12||||423.12|321.57|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|423.12||||423.12|291.95|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA [1260]|CIGNA PPO [126025]|423.12||||423.12|169.25|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|423.12||||423.12||321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GROUP PENSION ADMIN [1450]|GPA [145000]|423.12||||423.12|291.95|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|423.12||||423.12|211.56|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|423.12||||423.12|291.95|321.57|84.62
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]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|423.12||||423.12|0|321.57|84.62
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]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PHCS [1780]|PHCS MULTIPLAN [178000]|423.12||||423.12|291.95|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|Self-pay|Self-pay|423.12||||423.12|84.62|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TML [1980]|TML [198000]|423.12||||423.12|291.95|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|423.12||||423.12|164.68|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|423.12||||423.12||321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNICARE [2040]|UNICARE [204000]|423.12||||423.12||321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|423.12||||423.12||321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WEB TPA [2115]|WEB TPA [211500]|423.12||||423.12|291.95|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|423.12||||423.12|0|321.57|84.62
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]|423.12||||423.12|0|321.57|84.62
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|TML WC [212537]|423.12||||423.12||321.57|84.62
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|2838||||2838||2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2838||||2838|0.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2838||||2838|1104.55|2156.88|0.55
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]|2838||||2838|0|2156.88|0.55
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]|2838||||2838|2043.36|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2838||||2838|1419|2156.88|0.55
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]|2838||||2838|1419|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2838||||2838|2156.88|2156.88|0.55
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]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2838||||2838|1958.22|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2838||||2838|1135.2|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2838||||2838||2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2838||||2838|1958.22|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2838||||2838|0.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2838||||2838|1958.22|2156.88|0.55
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]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2838||||2838|0|2156.88|0.55
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]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2838||||2838|1958.22|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|2838||||2838|567.6|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|2838||||2838|1958.22|2156.88|0.55
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]|2838||||2838|1104.55|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2838||||2838||2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|2838||||2838||2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2838||||2838||2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|2838||||2838|1958.22|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2838||||2838|0|2156.88|0.55
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]|2838||||2838|0|2156.88|0.55
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2838||||2838||2156.88|0.55
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AARP [1000]|AARP [100000]|5.94||||5.94||4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA [1015]|AETNA [101529]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|4.28|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.97|4.51|1.19
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]|5.94||||5.94|2.97|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|4.51|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94||4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|Self-pay|Self-pay|5.94||||5.94|1.19|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94||4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNICARE [2040]|UNICARE [204000]|5.94||||5.94||4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94||4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94||4.51|1.19
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|20.65||||20.65||15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.65||||20.65|10.33|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.65||||20.65|14.87|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.65||||20.65|10.33|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.65||||20.65|10.33|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.65||||20.65|15.69|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20.65||||20.65|8.26|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.65||||20.65||15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.65||||20.65|10.33|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|20.65||||20.65|4.13|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.65||||20.65|8.04|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.65||||20.65||15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|20.65||||20.65||15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.65||||20.65||15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20.65||||20.65|14.25|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.65||||20.65|0|15.69|4.13
10724|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20.65||||20.65||15.69|4.13
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AARP [1000]|AARP [100000]|2796.03||||2796.03||2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA [1015]|AETNA [101529]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMBETTER [2930]|AMBETTER [293000]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2796.03||||2796.03|4.36|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2796.03||||2796.03|2013.14|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2796.03||||2796.03|1398.02|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2796.03||||2796.03|1398.02|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2796.03||||2796.03|2124.98|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA PPO [126025]|2796.03||||2796.03|1118.41|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2796.03||||2796.03||2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2796.03||||2796.03|4.36|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|Self-pay|Self-pay|2796.03||||2796.03|559.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|TML [1980]|TML [198000]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2796.03||||2796.03|1088.21|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2796.03||||2796.03||2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UNICARE [2040]|UNICARE [204000]|2796.03||||2796.03||2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2796.03||||2796.03||2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WEB TPA [2115]|WEB TPA [211500]|2796.03||||2796.03|1929.26|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2796.03||||2796.03|0|2124.98|4.36
107670|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TML WC [212537]|2796.03||||2796.03||2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|2796.03||||2796.03||2124.98|4.36
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]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMBETTER [2930]|AMBETTER [293000]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2796.03||||2796.03|1088.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2796.03||||2796.03|4.36|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2796.03||||2796.03|1088.21|2124.98|4.36
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]|2796.03||||2796.03|0|2124.98|4.36
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]|2796.03||||2796.03|2013.14|2124.98|4.36
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]|2796.03||||2796.03|1398.02|2124.98|4.36
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]|2796.03||||2796.03|1398.02|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2796.03||||2796.03|2124.98|2124.98|4.36
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]|2796.03||||2796.03|1088.21|2124.98|4.36
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]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2796.03||||2796.03|1929.26|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA PPO [126025]|2796.03||||2796.03|1118.41|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2796.03||||2796.03||2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2796.03||||2796.03|1929.26|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2796.03||||2796.03|4.36|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2796.03||||2796.03|1929.26|2124.98|4.36
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]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2796.03||||2796.03|1088.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2796.03||||2796.03|0|2124.98|4.36
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]|2796.03||||2796.03|1088.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2796.03||||2796.03|1929.26|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2796.03||||2796.03|1088.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|2796.03||||2796.03|559.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|TML [1980]|TML [198000]|2796.03||||2796.03|1929.26|2124.98|4.36
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]|2796.03||||2796.03|1088.21|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2796.03||||2796.03||2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNICARE [2040]|UNICARE [204000]|2796.03||||2796.03||2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2796.03||||2796.03||2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WEB TPA [2115]|WEB TPA [211500]|2796.03||||2796.03|1929.26|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2796.03||||2796.03|0|2124.98|4.36
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]|2796.03||||2796.03|0|2124.98|4.36
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TML WC [212537]|2796.03||||2796.03||2124.98|4.36
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|4.66||||4.66||3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.66||||4.66|2.33|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.66||||4.66|3.36|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.66||||4.66|2.33|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.66||||4.66|2.33|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.66||||4.66|3.54|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|4.66||||4.66|1.86|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.66||||4.66||3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.66||||4.66|2.33|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|4.66||||4.66|0.93|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.66||||4.66|1.81|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.66||||4.66||3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|4.66||||4.66||3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.66||||4.66||3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|4.66||||4.66|3.22|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.66||||4.66|0|3.54|0.93
1080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 10 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|4.66||||4.66||3.54|0.93
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]|625.68||||625.68|312.84|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|625.68||||625.68|312.84|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|450.49|475.52|125.14
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]|625.68||||625.68|312.84|475.52|125.14
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]|625.68||||625.68|312.84|475.52|125.14
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 TRADITIONAL OF TEXAS [115503]|625.68||||625.68|475.52|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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 - GREAT WEST [126009]|625.68||||625.68|431.72|475.52|125.14
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 PPO [126025]|625.68||||625.68|250.27|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|625.68||||625.68|312.84|475.52|125.14
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]|625.68||||625.68|431.72|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|625.68||||625.68|312.84|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|625.68||||625.68|431.72|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|431.72|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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|625.68||||625.68|125.14|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|625.68||||625.68|431.72|475.52|125.14
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]|625.68||||625.68|243.51|475.52|125.14
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]|625.68||||625.68|312.84|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|625.68||||625.68|312.84|475.52|125.14
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]|625.68||||625.68|312.84|475.52|125.14
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|625.68||||625.68|431.72|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|625.68||||625.68|0|475.52|125.14
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]|TML WC [212537]|625.68||||625.68|312.84|475.52|125.14
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]|717.03||||717.03||544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|717.03||||717.03|2.22|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|516.26|544.94|2.22
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]|717.03||||717.03|358.52|544.94|2.22
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]|717.03||||717.03|358.52|544.94|2.22
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 TRADITIONAL OF TEXAS [115503]|717.03||||717.03|544.94|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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 - GREAT WEST [126009]|717.03||||717.03|494.75|544.94|2.22
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 PPO [126025]|717.03||||717.03|286.81|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|717.03||||717.03||544.94|2.22
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]|717.03||||717.03|494.75|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|717.03||||717.03|2.22|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|717.03||||717.03|494.75|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03|494.75|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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|717.03||||717.03|143.41|544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TML [1980]|TML [198000]|717.03||||717.03|494.75|544.94|2.22
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]|717.03||||717.03|279.07|544.94|2.22
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]|717.03||||717.03||544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNICARE [2040]|UNICARE [204000]|717.03||||717.03||544.94|2.22
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]|717.03||||717.03||544.94|2.22
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|717.03||||717.03|494.75|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|717.03||||717.03|0|544.94|2.22
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]|TML WC [212537]|717.03||||717.03||544.94|2.22
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|60.59||||60.59||46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|60.59||||60.59|30.3|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60.59||||60.59|43.62|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60.59||||60.59|30.3|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60.59||||60.59|30.3|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|60.59||||60.59|46.05|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|60.59||||60.59|24.24|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|60.59||||60.59||46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|60.59||||60.59|30.3|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|60.59||||60.59|12.12|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60.59||||60.59|23.58|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60.59||||60.59||46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|60.59||||60.59||46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60.59||||60.59||46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|60.59||||60.59|41.81|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60.59||||60.59|0|46.05|12.12
10803|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXANDROLONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|60.59||||60.59||46.05|12.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11853.6||||11853.6|54.12|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11853.6||||11853.6|8534.59|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11853.6||||11853.6|5926.8|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11853.6||||11853.6|5926.8|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11853.6||||11853.6|9008.74|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|11853.6||||11853.6|5926.8|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11853.6||||11853.6|54.12|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|11853.6||||11853.6|2370.72|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11853.6||||11853.6|4613.42|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|11853.6||||11853.6|8178.98|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11853.6||||11853.6|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|11853.6||||11853.6||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|23707.2||||23707.2||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMBETTER [2930]|AMBETTER [293000]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23707.2||||23707.2|54.12|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23707.2||||23707.2|17069.18|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23707.2||||23707.2|11853.6|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23707.2||||23707.2|11853.6|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23707.2||||23707.2|18017.47|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA PPO [126025]|23707.2||||23707.2|11853.6|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23707.2||||23707.2||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23707.2||||23707.2|54.12|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|23707.2||||23707.2|4741.44|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|TML [1980]|TML [198000]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23707.2||||23707.2|9226.84|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23707.2||||23707.2||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNICARE [2040]|UNICARE [204000]|23707.2||||23707.2||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23707.2||||23707.2||18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WEB TPA [2115]|WEB TPA [211500]|23707.2||||23707.2|16357.97|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23707.2||||23707.2|0|18017.47|54.12
108080|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 5 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TML WC [212537]|23707.2||||23707.2||18017.47|54.12
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]|92.4||||92.4|46.2|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|0.51|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|66.53|70.22|0.51
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]|92.4||||92.4|46.2|70.22|0.51
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]|92.4||||92.4|46.2|70.22|0.51
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 TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|46.2|70.22|0.51
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]|92.4||||92.4|63.76|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|0.51|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|63.76|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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|92.4||||92.4|18.48|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|0.51
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]|92.4||||92.4|35.96|70.22|0.51
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]|92.4||||92.4|46.2|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|46.2|70.22|0.51
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]|92.4||||92.4|46.2|70.22|0.51
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|92.4||||92.4|0|70.22|0.51
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]|TML WC [212537]|92.4||||92.4|46.2|70.22|0.51
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]|145.2||||145.2|72.6|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|0.51|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|104.54|110.35|0.51
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]|145.2||||145.2|72.6|110.35|0.51
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]|145.2||||145.2|72.6|110.35|0.51
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 TRADITIONAL OF TEXAS [115503]|145.2||||145.2|110.35|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|72.6|110.35|0.51
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]|145.2||||145.2|100.19|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|0.51|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|100.19|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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|145.2||||145.2|29.04|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|145.2||||145.2|100.19|110.35|0.51
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]|145.2||||145.2|56.51|110.35|0.51
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]|145.2||||145.2|72.6|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|72.6|110.35|0.51
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]|145.2||||145.2|72.6|110.35|0.51
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|145.2||||145.2|0|110.35|0.51
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]|TML WC [212537]|145.2||||145.2|72.6|110.35|0.51
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]|144.54||||144.54|72.27|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMBETTER [2930]|AMBETTER [293000]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|144.54||||144.54|0.51|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|104.07|109.85|0.51
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]|144.54||||144.54|72.27|109.85|0.51
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]|144.54||||144.54|72.27|109.85|0.51
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 TRADITIONAL OF TEXAS [115503]|144.54||||144.54|109.85|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|144.54||||144.54|99.73|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA [1260]|CIGNA PPO [126025]|144.54||||144.54|57.82|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|144.54||||144.54|72.27|109.85|0.51
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]|144.54||||144.54|99.73|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|144.54||||144.54|0.51|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|144.54||||144.54|99.73|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|99.73|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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|144.54||||144.54|28.91|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|TML [1980]|TML [198000]|144.54||||144.54|99.73|109.85|0.51
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]|144.54||||144.54|56.25|109.85|0.51
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]|144.54||||144.54|72.27|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNICARE [2040]|UNICARE [204000]|144.54||||144.54|72.27|109.85|0.51
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]|144.54||||144.54|72.27|109.85|0.51
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WEB TPA [2115]|WEB TPA [211500]|144.54||||144.54|99.73|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|144.54||||144.54|0|109.85|0.51
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]|TML WC [212537]|144.54||||144.54|72.27|109.85|0.51
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]|477||||477||362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|0|362.52|95.4
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|AMBETTER [2930]|AMBETTER [293000]|477||||477|0|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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]|477||||477|0|362.52|95.4
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|477||||477|238.5|362.52|95.4
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 MEDICAID [1165]|BCBS MEDICAID [116504]|477||||477|185.65|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|343.44|362.52|95.4
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]|477||||477|238.5|362.52|95.4
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]|477||||477|238.5|362.52|95.4
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 TRADITIONAL OF TEXAS [115503]|477||||477|362.52|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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]|477||||477|0|362.52|95.4
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 - GREAT WEST [126009]|477||||477|329.13|362.52|95.4
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 PPO [126025]|477||||477|190.8|362.52|95.4
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|477||||477||362.52|95.4
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]|477||||477|329.13|362.52|95.4
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|477||||477|238.5|362.52|95.4
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|477||||477|329.13|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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]|477||||477|329.13|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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|477||||477|95.4|362.52|95.4
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|TML [1980]|TML [198000]|477||||477|329.13|362.52|95.4
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]|477||||477|185.65|362.52|95.4
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]|477||||477||362.52|95.4
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|UNICARE [2040]|UNICARE [204000]|477||||477||362.52|95.4
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]|477||||477||362.52|95.4
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|WEB TPA [2115]|WEB TPA [211500]|477||||477|329.13|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|477||||477|0|362.52|95.4
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]|TML WC [212537]|477||||477||362.52|95.4
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]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|1.29|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|28.51|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
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 TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|27.32|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|1.29|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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|39.6||||39.6|7.92|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|TML WC [212537]|39.6||||39.6|19.8|30.1|1.29
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|161.78||||161.78||122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|161.78||||161.78|1.38|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161.78||||161.78|116.48|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161.78||||161.78|80.89|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161.78||||161.78|80.89|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|161.78||||161.78|122.95|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|161.78||||161.78|64.71|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|161.78||||161.78||122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|161.78||||161.78|1.38|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|161.78||||161.78|32.36|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161.78||||161.78|62.96|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161.78||||161.78||122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|161.78||||161.78||122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161.78||||161.78||122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|161.78||||161.78|111.63|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161.78||||161.78|0|122.95|1.38
108131|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 500 MG/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|161.78||||161.78||122.95|1.38
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]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|1.29|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|28.51|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
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 TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|27.32|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|1.29|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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|39.6||||39.6|7.92|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|15.41|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|1.29
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]|39.6||||39.6|19.8|30.1|1.29
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|39.6||||39.6|0|30.1|1.29
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]|TML WC [212537]|39.6||||39.6|19.8|30.1|1.29
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|323.56||||323.56||245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|323.56||||323.56|1.38|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|323.56||||323.56|125.93|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|232.96|245.91|1.38
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]|323.56||||323.56|161.78|245.91|1.38
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]|323.56||||323.56|161.78|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|323.56||||323.56|245.91|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|323.56||||323.56|223.26|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|323.56||||323.56|129.42|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|323.56||||323.56||245.91|1.38
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]|323.56||||323.56|223.26|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|323.56||||323.56|1.38|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|323.56||||323.56|223.26|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|323.56||||323.56|223.26|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|323.56||||323.56|64.71|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|323.56||||323.56|223.26|245.91|1.38
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]|323.56||||323.56|125.93|245.91|1.38
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]|323.56||||323.56||245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|323.56||||323.56||245.91|1.38
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]|323.56||||323.56||245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|323.56||||323.56|223.26|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
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]|323.56||||323.56|0|245.91|1.38
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|323.56||||323.56||245.91|1.38
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.64||||2.64||2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|1.03|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.9|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.32|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.32|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|2.01|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64||2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.64||||2.64|0.53|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.64||||2.64|1.82|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|1.03|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64||2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.64||||2.64||2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64||2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64||2.01|0.53
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]|158.4||||158.4||120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|120.38|31.68
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 MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|114.05|120.38|31.68
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]|158.4||||158.4|79.2|120.38|31.68
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]|158.4||||158.4|79.2|120.38|31.68
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 TRADITIONAL OF TEXAS [115503]|158.4||||158.4|120.38|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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 - GREAT WEST [126009]|158.4||||158.4|109.3|120.38|31.68
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 PPO [126025]|158.4||||158.4|63.36|120.38|31.68
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4||120.38|31.68
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]|158.4||||158.4|109.3|120.38|31.68
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|120.38|31.68
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|109.3|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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|158.4||||158.4|31.68|120.38|31.68
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|TML [1980]|TML [198000]|158.4||||158.4|109.3|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4||120.38|31.68
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|UNICARE [2040]|UNICARE [204000]|158.4||||158.4||120.38|31.68
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]|158.4||||158.4||120.38|31.68
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|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
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]|TML WC [212537]|158.4||||158.4||120.38|31.68
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||11864.83|3122.32
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|0|11864.83|3122.32
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|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AMBETTER [2930]|AMBETTER [293000]|15611.62||||15611.62|0|11864.83|3122.32
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|6076.04|11864.83|3122.32
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|0|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15611.62||||15611.62|7805.81|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15611.62||||15611.62|6076.04|11864.83|3122.32
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|0|11864.83|3122.32
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|11240.37|11864.83|3122.32
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|11864.83|3122.32
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|7805.81|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15611.62||||15611.62|11864.83|11864.83|3122.32
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|6076.04|11864.83|3122.32
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|0|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15611.62||||15611.62|10772.02|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|CIGNA [1260]|CIGNA PPO [126025]|15611.62||||15611.62|6244.65|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15611.62||||15611.62||11864.83|3122.32
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|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15611.62||||15611.62|7805.81|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15611.62||||15611.62|10772.02|11864.83|3122.32
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|0|11864.83|3122.32
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|11864.83|3122.32
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|6076.04|11864.83|3122.32
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|0|11864.83|3122.32
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|11864.83|3122.32
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|6076.04|11864.83|3122.32
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|11864.83|3122.32
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|6076.04|11864.83|3122.32
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|3122.32|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|TML [1980]|TML [198000]|15611.62||||15611.62|10772.02|11864.83|3122.32
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|6076.04|11864.83|3122.32
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||11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UNICARE [2040]|UNICARE [204000]|15611.62||||15611.62||11864.83|3122.32
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||11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|WEB TPA [2115]|WEB TPA [211500]|15611.62||||15611.62|10772.02|11864.83|3122.32
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|0|11864.83|3122.32
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|0|11864.83|3122.32
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|WORKER'S COMP [2125]|TML WC [212537]|15611.62||||15611.62||11864.83|3122.32
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|316.8||||316.8||240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|316.8||||316.8|158.4|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316.8||||316.8|228.1|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316.8||||316.8|158.4|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316.8||||316.8|158.4|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|316.8||||316.8|240.77|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|316.8||||316.8|126.72|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|316.8||||316.8||240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|316.8||||316.8|158.4|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|316.8||||316.8|63.36|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|TML [1980]|TML [198000]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316.8||||316.8|123.3|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316.8||||316.8||240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|316.8||||316.8||240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316.8||||316.8||240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|316.8||||316.8|218.59|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316.8||||316.8|0|240.77|63.36
109034|ERX|0250 - PHARMACY-GENERAL|CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|316.8||||316.8||240.77|63.36
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|396||||396||300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMBETTER [2930]|AMBETTER [293000]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|396||||396|198|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|396||||396|154.12|300.96|79.2
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]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|285.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|198|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|198|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|396||||396|300.96|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|396||||396|273.24|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA PPO [126025]|396||||396|158.4|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|396||||396||300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|396||||396|198|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|396||||396|273.24|300.96|79.2
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]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|0|300.96|79.2
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]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|Self-pay|Self-pay|396||||396|79.2|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|TML [1980]|TML [198000]|396||||396|273.24|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|154.12|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396||300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNICARE [2040]|UNICARE [204000]|396||||396||300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396||300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WEB TPA [2115]|WEB TPA [211500]|396||||396|273.24|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396|0|300.96|79.2
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]|396||||396|0|300.96|79.2
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TML WC [212537]|396||||396||300.96|79.2
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AARP [1000]|AARP [100000]|89.57||||89.57||68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA [1015]|AETNA [101529]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMBETTER [2930]|AMBETTER [293000]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.57||||89.57|44.79|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.57||||89.57|34.86|68.07|17.91
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]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.57||||89.57|64.49|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.57||||89.57|44.79|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.57||||89.57|44.79|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|89.57||||89.57|68.07|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|89.57||||89.57|61.8|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA [1260]|CIGNA PPO [126025]|89.57||||89.57|35.83|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.57||||89.57||68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|89.57||||89.57|61.8|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.57||||89.57|44.79|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.57||||89.57|61.8|68.07|17.91
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]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.57||||89.57|0|68.07|17.91
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]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|89.57||||89.57|61.8|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|Self-pay|Self-pay|89.57||||89.57|17.91|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|TML [1980]|TML [198000]|89.57||||89.57|61.8|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.57||||89.57|34.86|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.57||||89.57||68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNICARE [2040]|UNICARE [204000]|89.57||||89.57||68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.57||||89.57||68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WEB TPA [2115]|WEB TPA [211500]|89.57||||89.57|61.8|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.57||||89.57|0|68.07|17.91
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]|89.57||||89.57|0|68.07|17.91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WORKER'S COMP [2125]|TML WC [212537]|89.57||||89.57||68.07|17.91
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|178.72||||178.72||135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|178.72||||178.72|89.36|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|178.72||||178.72|69.56|135.83|35.74
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]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178.72||||178.72|128.68|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178.72||||178.72|89.36|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178.72||||178.72|89.36|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|178.72||||178.72|135.83|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|178.72||||178.72|123.32|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|178.72||||178.72|71.49|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|178.72||||178.72||135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|178.72||||178.72|123.32|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|178.72||||178.72|89.36|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|178.72||||178.72|123.32|135.83|35.74
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]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178.72||||178.72|0|135.83|35.74
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]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|178.72||||178.72|123.32|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|Self-pay|Self-pay|178.72||||178.72|35.74|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|TML [1980]|TML [198000]|178.72||||178.72|123.32|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178.72||||178.72|69.56|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178.72||||178.72||135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|178.72||||178.72||135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178.72||||178.72||135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|178.72||||178.72|123.32|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178.72||||178.72|0|135.83|35.74
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]|178.72||||178.72|0|135.83|35.74
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|178.72||||178.72||135.83|35.74
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||159.6|42
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|0|159.6|42
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|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AMBETTER [2930]|AMBETTER [293000]|210||||210|0|159.6|42
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|81.73|159.6|42
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|0|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210||||210|105|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210||||210|81.73|159.6|42
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|0|159.6|42
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|151.2|159.6|42
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|159.6|42
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|105|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210||||210|159.6|159.6|42
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|81.73|159.6|42
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|0|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210||||210|144.9|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA PPO [126025]|210||||210|84|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210||||210||159.6|42
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|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210||||210|105|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210||||210|144.9|159.6|42
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|0|159.6|42
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|159.6|42
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|81.73|159.6|42
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|0|159.6|42
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|159.6|42
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|81.73|159.6|42
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|159.6|42
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|81.73|159.6|42
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|42|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|TML [1980]|TML [198000]|210||||210|144.9|159.6|42
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|81.73|159.6|42
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||159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UNICARE [2040]|UNICARE [204000]|210||||210||159.6|42
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||159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|WEB TPA [2115]|WEB TPA [211500]|210||||210|144.9|159.6|42
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|0|159.6|42
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|0|159.6|42
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TML WC [212537]|210||||210||159.6|42
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|213.61||||213.61||162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|213.61||||213.61|106.81|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.61||||213.61|153.8|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.61||||213.61|106.81|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.61||||213.61|106.81|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|213.61||||213.61|162.34|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|213.61||||213.61|85.44|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|213.61||||213.61||162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|213.61||||213.61|106.81|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|213.61||||213.61|42.72|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.61||||213.61|83.14|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.61||||213.61||162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|213.61||||213.61||162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.61||||213.61||162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|213.61||||213.61|147.39|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.61||||213.61|0|162.34|42.72
109773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINAGLIPTIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|213.61||||213.61||162.34|42.72
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AARP [1000]|AARP [100000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AETNA [1015]|AETNA [101529]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AMBETTER [2930]|AMBETTER [293000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA PPO [126025]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|Self-pay|Self-pay|9629||||9629|1925.8|1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|TML [1980]|TML [198000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UNICARE [2040]|UNICARE [204000]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|WEB TPA [2115]|WEB TPA [211500]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9629||||9629||1925.8|1925.8
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]|9629||||9629||1925.8|1925.8
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|WORKER'S COMP [2125]|TML WC [212537]|9629||||9629||1925.8|1925.8
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|19.8||||19.8||15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.8||||19.8|9.9|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.8||||19.8|7.71|15.05|3.96
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]|19.8||||19.8|0|15.05|3.96
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]|19.8||||19.8|14.26|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.8||||19.8|9.9|15.05|3.96
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]|19.8||||19.8|9.9|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.8||||19.8|15.05|15.05|3.96
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]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.8||||19.8|13.66|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.8||||19.8|7.92|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.8||||19.8||15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.8||||19.8|13.66|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.8||||19.8|9.9|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.8||||19.8|13.66|15.05|3.96
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]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.8||||19.8|0|15.05|3.96
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]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.8||||19.8|13.66|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|19.8||||19.8|3.96|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|19.8||||19.8|13.66|15.05|3.96
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]|19.8||||19.8|7.71|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.8||||19.8||15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.8||||19.8||15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.8||||19.8||15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.8||||19.8|13.66|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.8||||19.8|0|15.05|3.96
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]|19.8||||19.8|0|15.05|3.96
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.8||||19.8||15.05|3.96
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|16.25||||16.25||12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.25||||16.25|6.32|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.25||||16.25|8.13|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.25||||16.25|6.32|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|11.7|12.35|3.25
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]|16.25||||16.25|8.13|12.35|3.25
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]|16.25||||16.25|8.13|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.25||||16.25|12.35|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.25||||16.25|11.21|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|16.25||||16.25|6.5|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.25||||16.25||12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|16.25||||16.25|11.21|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.25||||16.25|8.13|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.25||||16.25|11.21|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.25||||16.25|6.32|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|16.25||||16.25|11.21|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.25||||16.25|6.32|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|Self-pay|Self-pay|16.25||||16.25|3.25|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|16.25||||16.25|11.21|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.25||||16.25||12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|16.25||||16.25||12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.25||||16.25||12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|16.25||||16.25|11.21|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|16.25||||16.25||12.35|3.25
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|128||||128||97.28|5.02
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]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|128||||128|0|97.28|5.02
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]|128||||128|49.82|97.28|5.02
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]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128||||128|5.02|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128||||128|49.82|97.28|5.02
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]|128||||128|0|97.28|5.02
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]|128||||128|92.16|97.28|5.02
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]|128||||128|64|97.28|5.02
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]|128||||128|64|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128||||128|97.28|97.28|5.02
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]|128||||128|49.82|97.28|5.02
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]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128||||128|88.32|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|128||||128|51.2|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128||||128||97.28|5.02
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]|128||||128|88.32|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128||||128|5.02|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128||||128|88.32|97.28|5.02
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]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128||||128|0|97.28|5.02
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]|128||||128|49.82|97.28|5.02
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]|128||||128|0|97.28|5.02
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]|128||||128|0|97.28|5.02
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]|128||||128|49.82|97.28|5.02
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]|128||||128|88.32|97.28|5.02
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]|128||||128|49.82|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|128||||128|25.6|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|128||||128|88.32|97.28|5.02
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]|128||||128|49.82|97.28|5.02
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]|128||||128||97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|128||||128||97.28|5.02
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]|128||||128||97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|128||||128|88.32|97.28|5.02
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]|128||||128|0|97.28|5.02
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]|128||||128|0|97.28|5.02
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|128||||128||97.28|5.02
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AARP [1000]|AARP [100000]|216.71||||216.71||164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA [1015]|AETNA [101529]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMBETTER [2930]|AMBETTER [293000]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.71||||216.71|108.36|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.71||||216.71|84.34|164.7|43.34
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]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.71||||216.71|156.03|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.71||||216.71|108.36|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.71||||216.71|108.36|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.71||||216.71|164.7|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.71||||216.71|149.53|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA [1260]|CIGNA PPO [126025]|216.71||||216.71|86.68|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.71||||216.71||164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|216.71||||216.71|149.53|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.71||||216.71|108.36|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.71||||216.71|149.53|164.7|43.34
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]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.71||||216.71|0|164.7|43.34
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]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|216.71||||216.71|149.53|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|Self-pay|Self-pay|216.71||||216.71|43.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|TML [1980]|TML [198000]|216.71||||216.71|149.53|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.71||||216.71|84.34|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.71||||216.71||164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNICARE [2040]|UNICARE [204000]|216.71||||216.71||164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.71||||216.71||164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WEB TPA [2115]|WEB TPA [211500]|216.71||||216.71|149.53|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.71||||216.71|0|164.7|43.34
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]|216.71||||216.71|0|164.7|43.34
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WORKER'S COMP [2125]|TML WC [212537]|216.71||||216.71||164.7|43.34
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]|458.04||||458.04|229.02|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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|AMBETTER [2930]|AMBETTER [293000]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|458.04||||458.04|229.02|348.11|91.61
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 MEDICAID [1165]|BCBS MEDICAID [116504]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|329.79|348.11|91.61
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]|458.04||||458.04|229.02|348.11|91.61
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]|458.04||||458.04|229.02|348.11|91.61
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 TRADITIONAL OF TEXAS [115503]|458.04||||458.04|348.11|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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 - GREAT WEST [126009]|458.04||||458.04|316.05|348.11|91.61
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 PPO [126025]|458.04||||458.04|183.22|348.11|91.61
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|458.04||||458.04|229.02|348.11|91.61
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]|458.04||||458.04|316.05|348.11|91.61
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|458.04||||458.04|229.02|348.11|91.61
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|458.04||||458.04|316.05|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|316.05|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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|458.04||||458.04|91.61|348.11|91.61
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|TML [1980]|TML [198000]|458.04||||458.04|316.05|348.11|91.61
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]|458.04||||458.04|178.27|348.11|91.61
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]|458.04||||458.04|229.02|348.11|91.61
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|UNICARE [2040]|UNICARE [204000]|458.04||||458.04|229.02|348.11|91.61
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]|458.04||||458.04|229.02|348.11|91.61
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|WEB TPA [2115]|WEB TPA [211500]|458.04||||458.04|316.05|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|458.04||||458.04|0|348.11|91.61
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]|TML WC [212537]|458.04||||458.04|229.02|348.11|91.61
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]|609.84||||609.84||463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AMBETTER [2930]|AMBETTER [293000]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.84||||609.84|304.92|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|439.08|463.48|121.97
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]|609.84||||609.84|304.92|463.48|121.97
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]|609.84||||609.84|304.92|463.48|121.97
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 TRADITIONAL OF TEXAS [115503]|609.84||||609.84|463.48|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.84||||609.84|420.79|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|CIGNA [1260]|CIGNA PPO [126025]|609.84||||609.84|243.94|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.84||||609.84||463.48|121.97
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]|609.84||||609.84|420.79|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.84||||609.84|304.92|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.84||||609.84|420.79|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84|420.79|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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|609.84||||609.84|121.97|463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|TML [1980]|TML [198000]|609.84||||609.84|420.79|463.48|121.97
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]|609.84||||609.84|237.35|463.48|121.97
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]|609.84||||609.84||463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UNICARE [2040]|UNICARE [204000]|609.84||||609.84||463.48|121.97
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]|609.84||||609.84||463.48|121.97
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|WEB TPA [2115]|WEB TPA [211500]|609.84||||609.84|420.79|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|609.84||||609.84|0|463.48|121.97
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]|TML WC [212537]|609.84||||609.84||463.48|121.97
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|90.85||||90.85||69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.85||||90.85|45.43|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.85||||90.85|65.41|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.85||||90.85|45.43|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.85||||90.85|45.43|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.85||||90.85|69.05|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.85||||90.85|36.34|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.85||||90.85||69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.85||||90.85|45.43|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|Self-pay|Self-pay|90.85||||90.85|18.17|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|TML [1980]|TML [198000]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.85||||90.85|35.36|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.85||||90.85||69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|90.85||||90.85||69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.85||||90.85||69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.85||||90.85|62.69|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.85||||90.85|0|69.05|18.17
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.85||||90.85||69.05|18.17
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.95||||8.95||6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.95||||8.95|4.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.95||||8.95|6.44|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.95||||8.95|4.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.95||||8.95|4.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.95||||8.95|6.8|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.95||||8.95|3.58|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.95||||8.95||6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.95||||8.95|4.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|Self-pay|Self-pay|8.95||||8.95|1.79|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.95||||8.95|3.48|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.95||||8.95||6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.95||||8.95||6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.95||||8.95||6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.95||||8.95|6.18|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.95||||8.95|0|6.8|1.79
11067|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.95||||8.95||6.8|1.79
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]|47.52||||47.52|23.76|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.52||||47.52|0.21|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|34.21|36.12|0.21
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]|47.52||||47.52|23.76|36.12|0.21
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]|47.52||||47.52|23.76|36.12|0.21
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 TRADITIONAL OF TEXAS [115503]|47.52||||47.52|36.12|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.52||||47.52|32.79|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|47.52||||47.52|19.01|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.52||||47.52|23.76|36.12|0.21
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]|47.52||||47.52|32.79|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.52||||47.52|0.21|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.52||||47.52|32.79|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|32.79|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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|47.52||||47.52|9.5|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|47.52||||47.52|32.79|36.12|0.21
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]|47.52||||47.52|18.49|36.12|0.21
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]|47.52||||47.52|23.76|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|47.52||||47.52|23.76|36.12|0.21
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]|47.52||||47.52|23.76|36.12|0.21
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|47.52||||47.52|32.79|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|47.52||||47.52|0|36.12|0.21
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]|TML WC [212537]|47.52||||47.52|23.76|36.12|0.21
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]|24.42||||24.42|12.21|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.42||||24.42|0.21|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|17.58|18.56|0.21
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]|24.42||||24.42|12.21|18.56|0.21
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]|24.42||||24.42|12.21|18.56|0.21
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 TRADITIONAL OF TEXAS [115503]|24.42||||24.42|18.56|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.42||||24.42|16.85|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|24.42||||24.42|9.77|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.42||||24.42|12.21|18.56|0.21
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]|24.42||||24.42|16.85|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.42||||24.42|0.21|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.42||||24.42|16.85|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|16.85|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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|24.42||||24.42|4.88|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|24.42||||24.42|16.85|18.56|0.21
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]|24.42||||24.42|9.5|18.56|0.21
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]|24.42||||24.42|12.21|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|24.42||||24.42|12.21|18.56|0.21
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]|24.42||||24.42|12.21|18.56|0.21
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|24.42||||24.42|16.85|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|24.42||||24.42|0|18.56|0.21
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]|TML WC [212537]|24.42||||24.42|12.21|18.56|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|52.8||||52.8|26.4|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|0.21|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|38.02|40.13|0.21
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]|52.8||||52.8|26.4|40.13|0.21
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]|52.8||||52.8|26.4|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|40.13|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8|26.4|40.13|0.21
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]|52.8||||52.8|36.43|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|0.21|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|36.43|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|52.8||||52.8|10.56|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|40.13|0.21
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]|52.8||||52.8|20.55|40.13|0.21
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]|52.8||||52.8|26.4|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8|26.4|40.13|0.21
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]|52.8||||52.8|26.4|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
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]|52.8||||52.8|0|40.13|0.21
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8|26.4|40.13|0.21
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]|6.49||||6.49||4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.49||||6.49|3.25|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|4.67|4.93|1.3
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]|6.49||||6.49|3.25|4.93|1.3
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]|6.49||||6.49|3.25|4.93|1.3
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 TRADITIONAL OF TEXAS [115503]|6.49||||6.49|4.93|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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 - GREAT WEST [126009]|6.49||||6.49|4.48|4.93|1.3
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 PPO [126025]|6.49||||6.49|2.6|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.49||||6.49||4.93|1.3
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]|6.49||||6.49|4.48|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.49||||6.49|3.25|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.49||||6.49|4.48|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49|4.48|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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|6.49||||6.49|1.3|4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|6.49||||6.49|4.48|4.93|1.3
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]|6.49||||6.49|2.53|4.93|1.3
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]|6.49||||6.49||4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|6.49||||6.49||4.93|1.3
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]|6.49||||6.49||4.93|1.3
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.49||||6.49|4.48|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|6.49||||6.49|0|4.93|1.3
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]|TML WC [212537]|6.49||||6.49||4.93|1.3
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AARP [1000]|AARP [100000]|6.41||||6.41||4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.41||||6.41|3.21|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.41||||6.41|4.62|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.41||||6.41|3.21|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.41||||6.41|3.21|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.41||||6.41|4.87|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.41||||6.41|2.56|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.41||||6.41||4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.41||||6.41|3.21|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|Self-pay|Self-pay|6.41||||6.41|1.28|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|TML [1980]|TML [198000]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.41||||6.41|2.49|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.41||||6.41||4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.41||||6.41||4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.41||||6.41||4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.41||||6.41|4.42|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.41||||6.41|0|4.87|1.28
11087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.41||||6.41||4.87|1.28
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|926.64||||926.64||704.25|185.33
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]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMBETTER [2930]|AMBETTER [293000]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|926.64||||926.64|360.65|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|926.64||||926.64|463.32|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|926.64||||926.64|360.65|704.25|185.33
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]|926.64||||926.64|0|704.25|185.33
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]|926.64||||926.64|667.18|704.25|185.33
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]|926.64||||926.64|463.32|704.25|185.33
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]|926.64||||926.64|463.32|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|926.64||||926.64|704.25|704.25|185.33
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]|926.64||||926.64|360.65|704.25|185.33
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]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|926.64||||926.64|639.38|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|926.64||||926.64|370.66|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|926.64||||926.64||704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|926.64||||926.64|639.38|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|926.64||||926.64|463.32|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|926.64||||926.64|639.38|704.25|185.33
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]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|926.64||||926.64|360.65|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|926.64||||926.64|0|704.25|185.33
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]|926.64||||926.64|360.65|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|926.64||||926.64|639.38|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|926.64||||926.64|360.65|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|926.64||||926.64|185.33|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|TML [1980]|TML [198000]|926.64||||926.64|639.38|704.25|185.33
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]|926.64||||926.64|360.65|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|926.64||||926.64||704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNICARE [2040]|UNICARE [204000]|926.64||||926.64||704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|926.64||||926.64||704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WEB TPA [2115]|WEB TPA [211500]|926.64||||926.64|639.38|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|926.64||||926.64|0|704.25|185.33
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]|926.64||||926.64|0|704.25|185.33
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|926.64||||926.64||704.25|185.33
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.47||||6.47||4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.47||||6.47|3.24|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.47||||6.47|2.52|4.92|1.29
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]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.47||||6.47|4.66|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.47||||6.47|3.24|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.47||||6.47|3.24|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.47||||6.47|4.92|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.47||||6.47|4.46|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.47||||6.47|2.59|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.47||||6.47||4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.47||||6.47|4.46|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.47||||6.47|3.24|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.47||||6.47|4.46|4.92|1.29
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]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.47||||6.47|0|4.92|1.29
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]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.47||||6.47|4.46|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|6.47||||6.47|1.29|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.47||||6.47|4.46|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.47||||6.47|2.52|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.47||||6.47||4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.47||||6.47||4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.47||||6.47||4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.47||||6.47|4.46|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.47||||6.47|0|4.92|1.29
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]|6.47||||6.47|0|4.92|1.29
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.47||||6.47||4.92|1.29
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AARP [1000]|AARP [100000]|45.15||||45.15||34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AETNA [1015]|AETNA [101529]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMBETTER [2930]|AMBETTER [293000]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|45.15||||45.15|22.58|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.15||||45.15|32.51|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.15||||45.15|22.58|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.15||||45.15|22.58|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|45.15||||45.15|34.31|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|CIGNA [1260]|CIGNA PPO [126025]|45.15||||45.15|18.06|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|45.15||||45.15||34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|45.15||||45.15|22.58|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|Self-pay|Self-pay|45.15||||45.15|9.03|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|TML [1980]|TML [198000]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.15||||45.15|17.57|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.15||||45.15||34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UNICARE [2040]|UNICARE [204000]|45.15||||45.15||34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.15||||45.15||34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WEB TPA [2115]|WEB TPA [211500]|45.15||||45.15|31.15|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.15||||45.15|0|34.31|9.03
111153|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE|57 g|WORKER'S COMP [2125]|TML WC [212537]|45.15||||45.15||34.31|9.03
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AARP [1000]|AARP [100000]|1035.94||||1035.94||787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AETNA [1015]|AETNA [101529]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AMBETTER [2930]|AMBETTER [293000]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1035.94||||1035.94|0.17|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1035.94||||1035.94|745.88|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1035.94||||1035.94|517.97|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1035.94||||1035.94|517.97|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1035.94||||1035.94|787.31|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|CIGNA [1260]|CIGNA PPO [126025]|1035.94||||1035.94|414.38|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1035.94||||1035.94||787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1035.94||||1035.94|0.17|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|Self-pay|Self-pay|1035.94||||1035.94|207.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|TML [1980]|TML [198000]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1035.94||||1035.94|403.19|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1035.94||||1035.94||787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|UNICARE [2040]|UNICARE [204000]|1035.94||||1035.94||787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1035.94||||1035.94||787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|WEB TPA [2115]|WEB TPA [211500]|1035.94||||1035.94|714.8|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1035.94||||1035.94|0|787.31|0.17
11118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 MG/5 ML) ORAL SOLN REPACK|120 mL|WORKER'S COMP [2125]|TML WC [212537]|1035.94||||1035.94||787.31|0.17
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.19||||7.19||5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.19||||7.19|3.6|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.19||||7.19|5.18|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.19||||7.19|3.6|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.19||||7.19|3.6|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.19||||7.19|5.46|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.19||||7.19|4.96|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.19||||7.19|2.88|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.19||||7.19||5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.19||||7.19|4.96|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.19||||7.19|3.6|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.19||||7.19|4.96|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.19||||7.19|4.96|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|7.19||||7.19|1.44|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.19||||7.19|4.96|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.19||||7.19|2.8|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.19||||7.19||5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.19||||7.19||5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.19||||7.19||5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.19||||7.19|4.96|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.19||||7.19||5.46|1.44
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|115.02||||115.02||87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|115.02||||115.02|57.51|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|115.02||||115.02|44.77|87.42|23
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]|115.02||||115.02|0|87.42|23
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]|115.02||||115.02|82.81|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115.02||||115.02|57.51|87.42|23
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]|115.02||||115.02|57.51|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|115.02||||115.02|87.42|87.42|23
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]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|115.02||||115.02|79.36|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|115.02||||115.02|46.01|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|115.02||||115.02||87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|115.02||||115.02|79.36|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|115.02||||115.02|57.51|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|115.02||||115.02|79.36|87.42|23
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]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115.02||||115.02|0|87.42|23
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]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|115.02||||115.02|79.36|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|115.02||||115.02|23|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|115.02||||115.02|79.36|87.42|23
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]|115.02||||115.02|44.77|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115.02||||115.02||87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|115.02||||115.02||87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115.02||||115.02||87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|115.02||||115.02|79.36|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115.02||||115.02|0|87.42|23
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]|115.02||||115.02|0|87.42|23
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|115.02||||115.02||87.42|23
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|128.68||||128.68||97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.68||||128.68|64.34|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.68||||128.68|92.65|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.68||||128.68|64.34|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.68||||128.68|64.34|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.68||||128.68|97.8|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|128.68||||128.68|51.47|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.68||||128.68||97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.68||||128.68|64.34|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|128.68||||128.68|25.74|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.68||||128.68|50.08|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.68||||128.68||97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|128.68||||128.68||97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.68||||128.68||97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|128.68||||128.68|88.79|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.68||||128.68|0|97.8|25.74
11143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.68||||128.68|64.34|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.68||||128.68|50.08|97.8|25.74
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]|128.68||||128.68|0|97.8|25.74
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]|128.68||||128.68|92.65|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.68||||128.68|64.34|97.8|25.74
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]|128.68||||128.68|64.34|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.68||||128.68|97.8|97.8|25.74
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]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.68||||128.68|88.79|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|128.68||||128.68|51.47|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|128.68||||128.68|88.79|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.68||||128.68|64.34|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.68||||128.68|88.79|97.8|25.74
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]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.68||||128.68|0|97.8|25.74
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]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|128.68||||128.68|88.79|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|128.68||||128.68|25.74|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|128.68||||128.68|88.79|97.8|25.74
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]|128.68||||128.68|50.08|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.68||||128.68||97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|128.68||||128.68|88.79|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.68||||128.68|0|97.8|25.74
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]|128.68||||128.68|0|97.8|25.74
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|128.68||||128.68||97.8|25.74
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.18||||10.18||7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.18||||10.18|5.09|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.18||||10.18|3.96|7.74|2.04
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]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.18||||10.18|7.33|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.18||||10.18|5.09|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.18||||10.18|5.09|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.18||||10.18|7.74|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.18||||10.18|7.02|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.18||||10.18|4.07|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.18||||10.18||7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.18||||10.18|7.02|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.18||||10.18|5.09|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.18||||10.18|7.02|7.74|2.04
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]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.18||||10.18|0|7.74|2.04
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]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.18||||10.18|7.02|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|Self-pay|Self-pay|10.18||||10.18|2.04|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.18||||10.18|7.02|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.18||||10.18|3.96|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.18||||10.18||7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.18||||10.18||7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.18||||10.18||7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.18||||10.18|7.02|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.18||||10.18|0|7.74|2.04
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]|10.18||||10.18|0|7.74|2.04
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.18||||10.18||7.74|2.04
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AARP [1000]|AARP [100000]|396||||396|198|300.96|0.16
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]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AETNA [1015]|AETNA [101529]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|154.12|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|396||||396|0.16|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|396||||396|154.12|300.96|0.16
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]|396||||396|0|300.96|0.16
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]|396||||396|285.12|300.96|0.16
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]|396||||396|198|300.96|0.16
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]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|396||||396|300.96|300.96|0.16
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]|396||||396|154.12|300.96|0.16
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]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|396||||396|273.24|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|396||||396|158.4|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|396||||396|0.16|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|396||||396|273.24|300.96|0.16
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]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|154.12|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|0|300.96|0.16
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]|396||||396|154.12|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|154.12|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|Self-pay|Self-pay|396||||396|79.2|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|TML [1980]|TML [198000]|396||||396|273.24|300.96|0.16
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]|396||||396|154.12|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UNICARE [2040]|UNICARE [204000]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|396||||396|273.24|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396|0|300.96|0.16
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]|396||||396|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|396||||396|198|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AARP [1000]|AARP [100000]|79.2||||79.2|39.6|300.96|0.16
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]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AETNA [1015]|AETNA [101529]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|30.82|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|0.16|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|30.82|300.96|0.16
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]|79.2||||79.2|0|300.96|0.16
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]|79.2||||79.2|57.02|300.96|0.16
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]|79.2||||79.2|39.6|300.96|0.16
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]|79.2||||79.2|39.6|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|60.19|300.96|0.16
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]|79.2||||79.2|30.82|300.96|0.16
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]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2|39.6|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|0.16|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|300.96|0.16
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]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.2||||79.2|30.82|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|0|300.96|0.16
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]|79.2||||79.2|30.82|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.2||||79.2|30.82|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|Self-pay|Self-pay|79.2||||79.2|15.84|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|TML [1980]|TML [198000]|79.2||||79.2|54.65|300.96|0.16
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]|79.2||||79.2|30.82|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2|39.6|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UNICARE [2040]|UNICARE [204000]|79.2||||79.2|39.6|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.2||||79.2|39.6|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.2||||79.2|0|300.96|0.16
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]|79.2||||79.2|0|300.96|0.16
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2|39.6|300.96|0.16
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|4.88||||4.88||3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.88||||4.88|2.44|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|3.51|3.71|0.98
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]|4.88||||4.88|2.44|3.71|0.98
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]|4.88||||4.88|2.44|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.88||||4.88|3.71|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.88||||4.88|3.37|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|4.88||||4.88|1.95|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.88||||4.88||3.71|0.98
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]|4.88||||4.88|3.37|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.88||||4.88|2.44|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.88||||4.88|3.37|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|3.37|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|4.88||||4.88|0.98|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|4.88||||4.88|3.37|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88||3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|4.88||||4.88||3.71|0.98
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]|4.88||||4.88||3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|4.88||||4.88|3.37|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|4.88||||4.88||3.71|0.98
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|273.15||||273.15||207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|273.15||||273.15|136.58|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|273.15||||273.15|196.67|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|273.15||||273.15|136.58|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|273.15||||273.15|136.58|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|273.15||||273.15|207.59|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|273.15||||273.15|109.26|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|273.15||||273.15||207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|273.15||||273.15|136.58|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|273.15||||273.15|54.63|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|273.15||||273.15|106.31|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|273.15||||273.15||207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|273.15||||273.15||207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|273.15||||273.15||207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|273.15||||273.15|188.47|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|273.15||||273.15|0|207.59|54.63
11240|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|273.15||||273.15||207.59|54.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|2034.12||||2034.12||1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMBETTER [2930]|AMBETTER [293000]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2034.12||||2034.12|1017.06|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2034.12||||2034.12|1464.57|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2034.12||||2034.12|1017.06|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2034.12||||2034.12|1017.06|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2034.12||||2034.12|1545.93|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA PPO [126025]|2034.12||||2034.12|813.65|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2034.12||||2034.12||1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2034.12||||2034.12|1017.06|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|2034.12||||2034.12|406.82|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|TML [1980]|TML [198000]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2034.12||||2034.12|791.68|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2034.12||||2034.12||1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNICARE [2040]|UNICARE [204000]|2034.12||||2034.12||1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2034.12||||2034.12||1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WEB TPA [2115]|WEB TPA [211500]|2034.12||||2034.12|1403.54|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2034.12||||2034.12|0|1545.93|406.82
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TML WC [212537]|2034.12||||2034.12||1545.93|406.82
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.2||||13.2||10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|5.14|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|9.5|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|6.6|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.6|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|10.03|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2||10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|0|10.03|2.64
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]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|Self-pay|Self-pay|13.2||||13.2|2.64|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.2||||13.2|9.11|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|5.14|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2||10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.2||||13.2||10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2||10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2|0|10.03|2.64
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]|13.2||||13.2|0|10.03|2.64
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2||10.03|2.64
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AARP [1000]|AARP [100000]|1393.66||||1393.66||1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AETNA [1015]|AETNA [101529]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AMBETTER [2930]|AMBETTER [293000]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1393.66||||1393.66|696.83|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1393.66||||1393.66|1003.44|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1393.66||||1393.66|696.83|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1393.66||||1393.66|696.83|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1393.66||||1393.66|1059.18|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA [1260]|CIGNA PPO [126025]|1393.66||||1393.66|557.46|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1393.66||||1393.66||1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|GROUP PENSION ADMIN [1450]|GPA [145000]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1393.66||||1393.66|696.83|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|PHCS [1780]|PHCS MULTIPLAN [178000]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|Self-pay|Self-pay|1393.66||||1393.66|278.73|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|TML [1980]|TML [198000]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1393.66||||1393.66|542.41|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1393.66||||1393.66||1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UNICARE [2040]|UNICARE [204000]|1393.66||||1393.66||1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1393.66||||1393.66||1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|WEB TPA [2115]|WEB TPA [211500]|1393.66||||1393.66|961.63|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1393.66||||1393.66|0|1059.18|278.73
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]|1393.66||||1393.66|0|1059.18|278.73
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|WORKER'S COMP [2125]|TML WC [212537]|1393.66||||1393.66||1059.18|278.73
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AARP [1000]|AARP [100000]|15.84||||15.84||12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA [1015]|AETNA [101529]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.84||||15.84|7.92|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.84||||15.84|11.4|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.84||||15.84|7.92|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.84||||15.84|7.92|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.84||||15.84|12.04|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|15.84||||15.84|6.34|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.84||||15.84||12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.84||||15.84|7.92|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|Self-pay|Self-pay|15.84||||15.84|3.17|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|TML [1980]|TML [198000]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.84||||15.84|6.16|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.84||||15.84||12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNICARE [2040]|UNICARE [204000]|15.84||||15.84||12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.84||||15.84||12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|15.84||||15.84|10.93|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.84||||15.84|0|12.04|3.17
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]|15.84||||15.84|0|12.04|3.17
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|15.84||||15.84||12.04|3.17
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||7277.76|1915.2
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|0|7277.76|1915.2
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|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AMBETTER [2930]|AMBETTER [293000]|9576||||9576|0|7277.76|1915.2
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|3726.98|7277.76|1915.2
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|0|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9576||||9576|4788|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9576||||9576|3726.98|7277.76|1915.2
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|0|7277.76|1915.2
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|6894.72|7277.76|1915.2
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|7277.76|1915.2
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|4788|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9576||||9576|7277.76|7277.76|1915.2
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|3726.98|7277.76|1915.2
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|0|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9576||||9576|6607.44|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|CIGNA [1260]|CIGNA PPO [126025]|9576||||9576|3830.4|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9576||||9576||7277.76|1915.2
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|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9576||||9576|4788|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9576||||9576|6607.44|7277.76|1915.2
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|0|7277.76|1915.2
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|7277.76|1915.2
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|3726.98|7277.76|1915.2
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|0|7277.76|1915.2
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|7277.76|1915.2
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|3726.98|7277.76|1915.2
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|7277.76|1915.2
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|3726.98|7277.76|1915.2
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|1915.2|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|TML [1980]|TML [198000]|9576||||9576|6607.44|7277.76|1915.2
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|3726.98|7277.76|1915.2
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||7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UNICARE [2040]|UNICARE [204000]|9576||||9576||7277.76|1915.2
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||7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|WEB TPA [2115]|WEB TPA [211500]|9576||||9576|6607.44|7277.76|1915.2
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|0|7277.76|1915.2
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|0|7277.76|1915.2
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|WORKER'S COMP [2125]|TML WC [212537]|9576||||9576||7277.76|1915.2
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|244.2||||244.2||185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244.2||||244.2|0.16|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.2||||244.2|175.82|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.2||||244.2|122.1|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.2||||244.2|122.1|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244.2||||244.2|185.59|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|244.2||||244.2|97.68|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244.2||||244.2||185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244.2||||244.2|0.16|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|Self-pay|Self-pay|244.2||||244.2|48.84|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|TML [1980]|TML [198000]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.2||||244.2|95.04|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.2||||244.2||185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|244.2||||244.2||185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.2||||244.2||185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|244.2||||244.2|168.5|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.2||||244.2|0|185.59|0.16
113475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|244.2||||244.2||185.59|0.16
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.16||||3.16||2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.16||||3.16|1.58|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.16||||3.16|1.23|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
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]|3.16||||3.16|2.28|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.16||||3.16|1.58|2.4|0.63
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]|3.16||||3.16|1.58|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.16||||3.16|2.4|2.4|0.63
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]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.16||||3.16|2.18|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.16||||3.16|1.26|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.16||||3.16||2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.16||||3.16|2.18|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.16||||3.16|1.58|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.16||||3.16|2.18|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.16||||3.16|0|2.4|0.63
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]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.16||||3.16|2.18|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|Self-pay|Self-pay|3.16||||3.16|0.63|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.16||||3.16|2.18|2.4|0.63
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]|3.16||||3.16|1.23|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.16||||3.16||2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.16||||3.16||2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.16||||3.16||2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.16||||3.16|2.18|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.16||||3.16|0|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.16||||3.16||2.4|0.63
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|162||||162||123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|162||||162|81|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|162||||162|63.05|123.12|32.4
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]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|162||||162|116.64|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|162||||162|81|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|162||||162|81|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|162||||162|123.12|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|162||||162|111.78|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|162||||162|64.8|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|162||||162||123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|162||||162|111.78|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|162||||162|81|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|162||||162|111.78|123.12|32.4
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]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162||||162|0|123.12|32.4
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]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|162||||162|111.78|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|162||||162|32.4|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|162||||162|111.78|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|162||||162|63.05|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162||||162||123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|162||||162||123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162||||162||123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|162||||162|111.78|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162||||162|0|123.12|32.4
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]|162||||162|0|123.12|32.4
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|162||||162||123.12|32.4
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|592.42||||592.42||450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|592.42||||592.42|296.21|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|592.42||||592.42|230.57|450.24|118.48
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]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|592.42||||592.42|426.54|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|592.42||||592.42|296.21|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|592.42||||592.42|296.21|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|592.42||||592.42|450.24|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|592.42||||592.42|408.77|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|592.42||||592.42|236.97|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|592.42||||592.42||450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|592.42||||592.42|408.77|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|592.42||||592.42|296.21|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|592.42||||592.42|408.77|450.24|118.48
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]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|592.42||||592.42|0|450.24|118.48
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]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|592.42||||592.42|408.77|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|592.42||||592.42|118.48|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|592.42||||592.42|408.77|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|592.42||||592.42|230.57|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|592.42||||592.42||450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|592.42||||592.42||450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|592.42||||592.42||450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|592.42||||592.42|408.77|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|592.42||||592.42|0|450.24|118.48
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]|592.42||||592.42|0|450.24|118.48
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|592.42||||592.42||450.24|118.48
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AARP [1000]|AARP [100000]|3.17||||3.17||2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA [1015]|AETNA [101529]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMBETTER [2930]|AMBETTER [293000]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.17||||3.17|1.59|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.17||||3.17|1.23|2.41|0.63
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]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.17||||3.17|2.28|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.17||||3.17|1.59|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.17||||3.17|1.59|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.17||||3.17|2.41|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.17||||3.17|2.19|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA [1260]|CIGNA PPO [126025]|3.17||||3.17|1.27|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.17||||3.17||2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|3.17||||3.17|2.19|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.17||||3.17|1.59|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.17||||3.17|2.19|2.41|0.63
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]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.17||||3.17|0|2.41|0.63
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]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|3.17||||3.17|2.19|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|Self-pay|Self-pay|3.17||||3.17|0.63|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|TML [1980]|TML [198000]|3.17||||3.17|2.19|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.17||||3.17|1.23|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.17||||3.17||2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNICARE [2040]|UNICARE [204000]|3.17||||3.17||2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.17||||3.17||2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WEB TPA [2115]|WEB TPA [211500]|3.17||||3.17|2.19|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.17||||3.17|0|2.41|0.63
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]|3.17||||3.17|0|2.41|0.63
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WORKER'S COMP [2125]|TML WC [212537]|3.17||||3.17||2.41|0.63
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AARP [1000]|AARP [100000]|1650||||1650|825|1254|150.22
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]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AETNA [1015]|AETNA [101529]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AMBETTER [2930]|AMBETTER [293000]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1650||||1650|642.18|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1650||||1650|150.22|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1650||||1650|642.18|1254|150.22
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]|1650||||1650|0|1254|150.22
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]|1650||||1650|1188|1254|150.22
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]|1650||||1650|825|1254|150.22
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]|1650||||1650|825|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1650||||1650|1254|1254|150.22
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]|1650||||1650|642.18|1254|150.22
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]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1650||||1650|1138.5|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|CIGNA [1260]|CIGNA PPO [126025]|1650||||1650|660|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1650||||1650|825|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|GROUP PENSION ADMIN [1450]|GPA [145000]|1650||||1650|1138.5|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1650||||1650|150.22|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1650||||1650|1138.5|1254|150.22
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]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1650||||1650|642.18|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1650||||1650|0|1254|150.22
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]|1650||||1650|642.18|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|PHCS [1780]|PHCS MULTIPLAN [178000]|1650||||1650|1138.5|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1650||||1650|642.18|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|Self-pay|Self-pay|1650||||1650|330|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|TML [1980]|TML [198000]|1650||||1650|1138.5|1254|150.22
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]|1650||||1650|642.18|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1650||||1650|825|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UNICARE [2040]|UNICARE [204000]|1650||||1650|825|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1650||||1650|825|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|WEB TPA [2115]|WEB TPA [211500]|1650||||1650|1138.5|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1650||||1650|0|1254|150.22
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]|1650||||1650|0|1254|150.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|WORKER'S COMP [2125]|TML WC [212537]|1650||||1650|825|1254|150.22
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]|168.56||||168.56|84.28|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|168.56||||168.56|1.07|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|121.36|128.11|1.07
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]|168.56||||168.56|84.28|128.11|1.07
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]|168.56||||168.56|84.28|128.11|1.07
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 TRADITIONAL OF TEXAS [115503]|168.56||||168.56|128.11|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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 - GREAT WEST [126009]|168.56||||168.56|116.31|128.11|1.07
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 PPO [126025]|168.56||||168.56|67.42|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|168.56||||168.56|84.28|128.11|1.07
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]|168.56||||168.56|116.31|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|168.56||||168.56|1.07|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|168.56||||168.56|116.31|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|116.31|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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|168.56||||168.56|33.71|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|168.56||||168.56|116.31|128.11|1.07
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]|168.56||||168.56|65.6|128.11|1.07
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]|168.56||||168.56|84.28|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|168.56||||168.56|84.28|128.11|1.07
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]|168.56||||168.56|84.28|128.11|1.07
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|168.56||||168.56|116.31|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|168.56||||168.56|0|128.11|1.07
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]|TML WC [212537]|168.56||||168.56|84.28|128.11|1.07
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|415.8||||415.8||316.01|30.39
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]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|415.8||||415.8|161.83|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|415.8||||415.8|30.39|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|415.8||||415.8|161.83|316.01|30.39
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]|415.8||||415.8|0|316.01|30.39
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]|415.8||||415.8|299.38|316.01|30.39
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]|415.8||||415.8|207.9|316.01|30.39
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]|415.8||||415.8|207.9|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|415.8||||415.8|316.01|316.01|30.39
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]|415.8||||415.8|161.83|316.01|30.39
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]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|415.8||||415.8|286.9|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|415.8||||415.8|166.32|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|415.8||||415.8||316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|415.8||||415.8|286.9|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|415.8||||415.8|30.39|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|415.8||||415.8|286.9|316.01|30.39
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]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|415.8||||415.8|161.83|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|415.8||||415.8|0|316.01|30.39
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]|415.8||||415.8|161.83|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|415.8||||415.8|286.9|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|415.8||||415.8|161.83|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|415.8||||415.8|83.16|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|415.8||||415.8|286.9|316.01|30.39
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]|415.8||||415.8|161.83|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|415.8||||415.8||316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|415.8||||415.8||316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|415.8||||415.8||316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|415.8||||415.8|286.9|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|415.8||||415.8|0|316.01|30.39
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]|415.8||||415.8|0|316.01|30.39
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|415.8||||415.8||316.01|30.39
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|66.53|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|66.53|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|35.96|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4||70.22|18.48
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4||70.22|18.48
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.7||||3.7||2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.7||||3.7|1.85|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.7||||3.7|1.44|2.81|0.74
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]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.7||||3.7|2.66|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.7||||3.7|1.85|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.7||||3.7|1.85|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.7||||3.7|2.81|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.7||||3.7|2.55|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.7||||3.7|1.48|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.7||||3.7||2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.7||||3.7|2.55|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.7||||3.7|1.85|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.7||||3.7|2.55|2.81|0.74
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]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.7||||3.7|0|2.81|0.74
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]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.7||||3.7|2.55|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|Self-pay|Self-pay|3.7||||3.7|0.74|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.7||||3.7|2.55|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.7||||3.7|1.44|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.7||||3.7||2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.7||||3.7||2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.7||||3.7||2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.7||||3.7|2.55|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.7||||3.7|0|2.81|0.74
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]|3.7||||3.7|0|2.81|0.74
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.7||||3.7||2.81|0.74
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|59.4||||59.4||45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|23.12|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|23.12|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
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]|59.4||||59.4|42.77|45.14|11.88
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]|59.4||||59.4|29.7|45.14|11.88
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]|59.4||||59.4|29.7|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|45.14|45.14|11.88
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]|59.4||||59.4|23.12|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4||45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|23.12|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|0|45.14|11.88
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]|59.4||||59.4|23.12|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|23.12|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|59.4||||59.4|11.88|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|59.4||||59.4|40.99|45.14|11.88
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]|59.4||||59.4|23.12|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4||45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|59.4||||59.4||45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4||45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4|0|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4||45.14|11.88
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18||3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|1.63|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.18||||4.18|3.01|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|2.09|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.18||||4.18|2.09|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|3.18|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18||3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.18||||4.18|1.63|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18||3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18||3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18||3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18||3.18|0.84
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|41.58||||41.58||31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.58||||41.58|20.79|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.58||||41.58|16.18|31.6|8.32
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]|41.58||||41.58|0|31.6|8.32
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]|41.58||||41.58|29.94|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.58||||41.58|20.79|31.6|8.32
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]|41.58||||41.58|20.79|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.58||||41.58|31.6|31.6|8.32
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]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.58||||41.58|28.69|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|41.58||||41.58|16.63|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.58||||41.58||31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|41.58||||41.58|28.69|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.58||||41.58|20.79|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.58||||41.58|28.69|31.6|8.32
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]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.58||||41.58|0|31.6|8.32
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]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|41.58||||41.58|28.69|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|41.58||||41.58|8.32|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|41.58||||41.58|28.69|31.6|8.32
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]|41.58||||41.58|16.18|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.58||||41.58||31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|41.58||||41.58||31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.58||||41.58||31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|41.58||||41.58|28.69|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.58||||41.58|0|31.6|8.32
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]|41.58||||41.58|0|31.6|8.32
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|41.58||||41.58||31.6|8.32
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|52.8||||52.8|26.4|40.13|6.7
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]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|20.55|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|6.7|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|20.55|40.13|6.7
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]|52.8||||52.8|0|40.13|6.7
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]|52.8||||52.8|38.02|40.13|6.7
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]|52.8||||52.8|26.4|40.13|6.7
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]|52.8||||52.8|26.4|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|40.13|40.13|6.7
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]|52.8||||52.8|20.55|40.13|6.7
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]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8|26.4|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|6.7|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|40.13|6.7
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]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|20.55|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|0|40.13|6.7
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]|52.8||||52.8|20.55|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|20.55|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|Self-pay|Self-pay|52.8||||52.8|10.56|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|40.13|6.7
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]|52.8||||52.8|20.55|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8|26.4|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8|26.4|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8|26.4|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8|0|40.13|6.7
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]|52.8||||52.8|0|40.13|6.7
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8|26.4|40.13|6.7
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|39.34||||39.34||29.9|7.87
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]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.34||||39.34|15.31|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.34||||39.34|19.67|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.34||||39.34|15.31|29.9|7.87
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]|39.34||||39.34|0|29.9|7.87
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]|39.34||||39.34|28.32|29.9|7.87
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]|39.34||||39.34|19.67|29.9|7.87
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]|39.34||||39.34|19.67|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.34||||39.34|29.9|29.9|7.87
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]|39.34||||39.34|15.31|29.9|7.87
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]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.34||||39.34|27.14|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|39.34||||39.34|15.74|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.34||||39.34||29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.34||||39.34|27.14|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.34||||39.34|19.67|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.34||||39.34|27.14|29.9|7.87
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]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.34||||39.34|15.31|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.34||||39.34|0|29.9|7.87
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]|39.34||||39.34|15.31|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.34||||39.34|27.14|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.34||||39.34|15.31|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|Self-pay|Self-pay|39.34||||39.34|7.87|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|TML [1980]|TML [198000]|39.34||||39.34|27.14|29.9|7.87
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]|39.34||||39.34|15.31|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.34||||39.34||29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|39.34||||39.34||29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.34||||39.34||29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|39.34||||39.34|27.14|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.34||||39.34|0|29.9|7.87
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]|39.34||||39.34|0|29.9|7.87
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|39.34||||39.34||29.9|7.87
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|114.71||||114.71||87.18|22.94
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]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114.71||||114.71|44.65|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|114.71||||114.71|57.36|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|114.71||||114.71|44.65|87.18|22.94
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]|114.71||||114.71|0|87.18|22.94
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]|114.71||||114.71|82.59|87.18|22.94
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]|114.71||||114.71|57.36|87.18|22.94
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]|114.71||||114.71|57.36|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|114.71||||114.71|87.18|87.18|22.94
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]|114.71||||114.71|44.65|87.18|22.94
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]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|114.71||||114.71|79.15|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|114.71||||114.71|45.88|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|114.71||||114.71||87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|114.71||||114.71|79.15|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|114.71||||114.71|57.36|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|114.71||||114.71|79.15|87.18|22.94
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]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114.71||||114.71|44.65|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114.71||||114.71|0|87.18|22.94
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]|114.71||||114.71|44.65|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|114.71||||114.71|79.15|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114.71||||114.71|44.65|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|114.71||||114.71|22.94|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|TML [1980]|TML [198000]|114.71||||114.71|79.15|87.18|22.94
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]|114.71||||114.71|44.65|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114.71||||114.71||87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|114.71||||114.71||87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114.71||||114.71||87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|114.71||||114.71|79.15|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114.71||||114.71|0|87.18|22.94
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]|114.71||||114.71|0|87.18|22.94
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|114.71||||114.71||87.18|22.94
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AARP [1000]|AARP [100000]|2310||||2310||1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AETNA [1015]|AETNA [101529]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AMBETTER [2930]|AMBETTER [293000]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2310||||2310|5.98|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2310||||2310|1663.2|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2310||||2310|1155|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2310||||2310|1155|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2310||||2310|1755.6|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|CIGNA [1260]|CIGNA PPO [126025]|2310||||2310|924|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2310||||2310||1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2310||||2310|5.98|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|Self-pay|Self-pay|2310||||2310|462|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|TML [1980]|TML [198000]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2310||||2310|899.05|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2310||||2310||1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|UNICARE [2040]|UNICARE [204000]|2310||||2310||1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2310||||2310||1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|WEB TPA [2115]|WEB TPA [211500]|2310||||2310|1593.9|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2310||||2310|0|1755.6|5.98
11565|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION|1,200 mg|WORKER'S COMP [2125]|TML WC [212537]|2310||||2310||1755.6|5.98
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AARP [1000]|AARP [100000]|667.53||||667.53||507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AETNA [1015]|AETNA [101529]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|667.53||||667.53|333.77|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|667.53||||667.53|480.62|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|667.53||||667.53|333.77|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|667.53||||667.53|333.77|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|667.53||||667.53|507.32|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|667.53||||667.53|267.01|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|667.53||||667.53||507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|667.53||||667.53|333.77|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|Self-pay|Self-pay|667.53||||667.53|133.51|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|TML [1980]|TML [198000]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|667.53||||667.53|259.8|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|667.53||||667.53||507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UNICARE [2040]|UNICARE [204000]|667.53||||667.53||507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|667.53||||667.53||507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|667.53||||667.53|460.6|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|667.53||||667.53|0|507.32|133.51
11567|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|667.53||||667.53||507.32|133.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|397.98||||397.98||302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|397.98||||397.98|198.99|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|397.98||||397.98|154.89|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|286.55|302.46|79.6
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]|397.98||||397.98|198.99|302.46|79.6
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]|397.98||||397.98|198.99|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|397.98||||397.98|302.46|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|397.98||||397.98|274.61|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|397.98||||397.98|159.19|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|397.98||||397.98||302.46|79.6
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]|397.98||||397.98|274.61|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|397.98||||397.98|198.99|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|397.98||||397.98|274.61|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|397.98||||397.98|274.61|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|397.98||||397.98|79.6|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|397.98||||397.98|274.61|302.46|79.6
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]|397.98||||397.98|154.89|302.46|79.6
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]|397.98||||397.98||302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|397.98||||397.98||302.46|79.6
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]|397.98||||397.98||302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|397.98||||397.98|274.61|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
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]|397.98||||397.98|0|302.46|79.6
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|397.98||||397.98||302.46|79.6
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.47||||2.47||1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.47||||2.47|1.24|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.47||||2.47|1.78|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.47||||2.47|1.24|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.47||||2.47|1.24|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.47||||2.47|1.88|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.47||||2.47|0.99|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.47||||2.47||1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.47||||2.47|1.24|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|Self-pay|Self-pay|2.47||||2.47|0.49|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.47||||2.47|0.96|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.47||||2.47||1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.47||||2.47||1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.47||||2.47||1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.47||||2.47|1.7|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.47||||2.47|0|1.88|0.49
11599|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.47||||2.47||1.88|0.49
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|78.6||||78.6||59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|78.6||||78.6|39.3|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|78.6||||78.6|30.59|59.74|15.72
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]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78.6||||78.6|56.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78.6||||78.6|39.3|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78.6||||78.6|39.3|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|78.6||||78.6|59.74|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|78.6||||78.6|54.23|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|78.6||||78.6|31.44|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|78.6||||78.6||59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|78.6||||78.6|54.23|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|78.6||||78.6|39.3|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|78.6||||78.6|54.23|59.74|15.72
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]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.6||||78.6|0|59.74|15.72
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]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|78.6||||78.6|54.23|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|78.6||||78.6|15.72|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|78.6||||78.6|54.23|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78.6||||78.6|30.59|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.6||||78.6||59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|78.6||||78.6||59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.6||||78.6||59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|78.6||||78.6|54.23|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.6||||78.6|0|59.74|15.72
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]|78.6||||78.6|0|59.74|15.72
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|78.6||||78.6||59.74|15.72
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AARP [1000]|AARP [100000]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AETNA [1015]|AETNA [101529]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMBETTER [2930]|AMBETTER [293000]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1306.67||||1306.67|3.39|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1306.67||||1306.67|940.8|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1306.67||||1306.67|993.07|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|CIGNA [1260]|CIGNA PPO [126025]|1306.67||||1306.67|522.67|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1306.67||||1306.67|3.39|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|Self-pay|Self-pay|1306.67||||1306.67|261.33|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|TML [1980]|TML [198000]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1306.67||||1306.67|508.56|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UNICARE [2040]|UNICARE [204000]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1306.67||||1306.67|653.34|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WEB TPA [2115]|WEB TPA [211500]|1306.67||||1306.67|901.6|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1306.67||||1306.67|0|993.07|3.39
11627|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION|10 g|WORKER'S COMP [2125]|TML WC [212537]|1306.67||||1306.67|653.34|993.07|3.39
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AARP [1000]|AARP [100000]|79.2||||79.2||60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|39.6|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.2||||79.2|57.02|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.2||||79.2|39.6|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.2||||79.2|39.6|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|60.19|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2||60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|39.6|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|Self-pay|Self-pay|79.2||||79.2|15.84|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|TML [1980]|TML [198000]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.2||||79.2|30.82|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2||60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UNICARE [2040]|UNICARE [204000]|79.2||||79.2||60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.2||||79.2||60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.2||||79.2|0|60.19|15.84
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2||60.19|15.84
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82.64||||82.64|0.18|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82.64||||82.64|59.5|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82.64||||82.64|62.81|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|82.64||||82.64|33.06|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82.64||||82.64|0.18|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|82.64||||82.64|16.53|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82.64||||82.64|32.16|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82.64||||82.64|41.32|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|82.64||||82.64|57.02|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82.64||||82.64|0|62.81|0.18
116345|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|82.64||||82.64|41.32|62.81|0.18
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AARP [1000]|AARP [100000]|224.4||||224.4||170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AETNA [1015]|AETNA [101529]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AMBETTER [2930]|AMBETTER [293000]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|224.4||||224.4|112.2|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|224.4||||224.4|161.57|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|224.4||||224.4|112.2|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|224.4||||224.4|112.2|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|224.4||||224.4|170.54|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA [1260]|CIGNA PPO [126025]|224.4||||224.4|89.76|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|224.4||||224.4||170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|224.4||||224.4|112.2|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|Self-pay|Self-pay|224.4||||224.4|44.88|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|TML [1980]|TML [198000]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|224.4||||224.4|87.34|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|224.4||||224.4||170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|UNICARE [2040]|UNICARE [204000]|224.4||||224.4||170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|224.4||||224.4||170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|WEB TPA [2115]|WEB TPA [211500]|224.4||||224.4|154.84|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|224.4||||224.4|0|170.54|44.88
11635|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION|20 mg|WORKER'S COMP [2125]|TML WC [212537]|224.4||||224.4||170.54|44.88
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AARP [1000]|AARP [100000]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA [1015]|AETNA [101529]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMBETTER [2930]|AMBETTER [293000]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.07||||46.07|23.04|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.07||||46.07|33.17|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.07||||46.07|23.04|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.07||||46.07|23.04|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.07||||46.07|35.01|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA [1260]|CIGNA PPO [126025]|46.07||||46.07|18.43|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.07||||46.07|23.04|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|Self-pay|Self-pay|46.07||||46.07|9.21|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|TML [1980]|TML [198000]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.07||||46.07|17.93|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNICARE [2040]|UNICARE [204000]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WEB TPA [2115]|WEB TPA [211500]|46.07||||46.07|31.79|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.07||||46.07|0|35.01|3.43
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]|46.07||||46.07|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WORKER'S COMP [2125]|TML WC [212537]|46.07||||46.07||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AARP [1000]|AARP [100000]|17.16||||17.16||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA [1015]|AETNA [101529]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMBETTER [2930]|AMBETTER [293000]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.16||||17.16|8.58|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.16||||17.16|12.36|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.16||||17.16|8.58|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.16||||17.16|8.58|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.16||||17.16|13.04|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA [1260]|CIGNA PPO [126025]|17.16||||17.16|6.86|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.16||||17.16||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.16||||17.16|8.58|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|Self-pay|Self-pay|17.16||||17.16|3.43|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|TML [1980]|TML [198000]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.16||||17.16|6.68|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.16||||17.16||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNICARE [2040]|UNICARE [204000]|17.16||||17.16||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.16||||17.16||35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WEB TPA [2115]|WEB TPA [211500]|17.16||||17.16|11.84|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.16||||17.16|0|35.01|3.43
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]|17.16||||17.16|0|35.01|3.43
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WORKER'S COMP [2125]|TML WC [212537]|17.16||||17.16||35.01|3.43
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]|5854.36||||5854.36||4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMBETTER [2930]|AMBETTER [293000]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5854.36||||5854.36|2927.18|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|4215.14|4449.31|1170.87
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]|5854.36||||5854.36|2927.18|4449.31|1170.87
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]|5854.36||||5854.36|2927.18|4449.31|1170.87
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 TRADITIONAL OF TEXAS [115503]|5854.36||||5854.36|4449.31|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5854.36||||5854.36|4039.51|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA [1260]|CIGNA PPO [126025]|5854.36||||5854.36|2341.74|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5854.36||||5854.36||4449.31|1170.87
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]|5854.36||||5854.36|4039.51|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5854.36||||5854.36|2927.18|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5854.36||||5854.36|4039.51|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36|4039.51|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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|5854.36||||5854.36|1170.87|4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|TML [1980]|TML [198000]|5854.36||||5854.36|4039.51|4449.31|1170.87
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]|5854.36||||5854.36|2278.52|4449.31|1170.87
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]|5854.36||||5854.36||4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNICARE [2040]|UNICARE [204000]|5854.36||||5854.36||4449.31|1170.87
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]|5854.36||||5854.36||4449.31|1170.87
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WEB TPA [2115]|WEB TPA [211500]|5854.36||||5854.36|4039.51|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|5854.36||||5854.36|0|4449.31|1170.87
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]|TML WC [212537]|5854.36||||5854.36||4449.31|1170.87
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|385.44||||385.44||292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|385.44||||385.44|1.96|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|385.44||||385.44|277.52|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|385.44||||385.44|192.72|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|385.44||||385.44|192.72|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|385.44||||385.44|292.93|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|385.44||||385.44|154.18|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|385.44||||385.44||292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|385.44||||385.44|1.96|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|385.44||||385.44|77.09|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|385.44||||385.44|150.01|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|385.44||||385.44||292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|385.44||||385.44||292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|385.44||||385.44||292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|385.44||||385.44|265.95|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|385.44||||385.44|0|292.93|1.96
11691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|385.44||||385.44||292.93|1.96
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|20||||20||15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20||||20|10|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20||||20|7.78|15.2|4
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]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|14.4|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|10|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20||||20|15.2|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20||||20|13.8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|20||||20|8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20||||20||15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20||||20|10|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20||||20|13.8|15.2|4
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]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|0|15.2|4
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]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|20||||20|4|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|20||||20|13.8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20|7.78|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|20||||20||15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|20||||20|13.8|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20|0|15.2|4
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]|20||||20|0|15.2|4
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|20||||20||15.2|4
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47||1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.47||||1.47|0.74|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.47||||1.47|0.57|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|1.06|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.74|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.74|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.47||||1.47|1.12|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.47||||1.47|1.01|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.47||||1.47|0.59|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.47||||1.47||1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.47||||1.47|0.74|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.47||||1.47|1.01|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0|1.12|0.29
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]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.29|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.47||||1.47|1.01|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.57|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47||1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.47||||1.47||1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47||1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.47||||1.47|1.01|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47|0|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.47||||1.47||1.12|0.29
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122.9||||122.9|2.73|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122.9||||122.9|88.49|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122.9||||122.9|61.45|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122.9||||122.9|61.45|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122.9||||122.9|93.4|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|122.9||||122.9|49.16|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122.9||||122.9|2.73|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|122.9||||122.9|24.58|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122.9||||122.9|47.83|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|122.9||||122.9|84.8|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122.9||||122.9|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|122.9||||122.9||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|51.75||||51.75||93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.75||||51.75|2.73|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.75||||51.75|20.14|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|37.26|93.4|2.73
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]|51.75||||51.75|25.88|93.4|2.73
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]|51.75||||51.75|25.88|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.75||||51.75|39.33|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.75||||51.75|35.71|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|51.75||||51.75|20.7|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.75||||51.75||93.4|2.73
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]|51.75||||51.75|35.71|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.75||||51.75|2.73|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.75||||51.75|35.71|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|51.75||||51.75|35.71|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|51.75||||51.75|10.35|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|51.75||||51.75|35.71|93.4|2.73
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]|51.75||||51.75|20.14|93.4|2.73
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]|51.75||||51.75||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|51.75||||51.75||93.4|2.73
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]|51.75||||51.75||93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|51.75||||51.75|35.71|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
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]|51.75||||51.75|0|93.4|2.73
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|51.75||||51.75||93.4|2.73
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AARP [1000]|AARP [100000]|772.73||||772.73||587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AETNA [1015]|AETNA [101529]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|772.73||||772.73|386.37|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|772.73||||772.73|556.37|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|772.73||||772.73|386.37|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|772.73||||772.73|386.37|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|772.73||||772.73|587.27|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|772.73||||772.73|309.09|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|772.73||||772.73||587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|772.73||||772.73|386.37|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|Self-pay|Self-pay|772.73||||772.73|154.55|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|TML [1980]|TML [198000]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|772.73||||772.73|300.75|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|772.73||||772.73||587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|UNICARE [2040]|UNICARE [204000]|772.73||||772.73||587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|772.73||||772.73||587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|772.73||||772.73|533.18|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|772.73||||772.73|0|587.27|154.55
117122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS,DIPHTHERIA TOXOID PED (PF) 5 LF UNIT-25 LF UNIT/0.5 ML IM SUSP|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|772.73||||772.73||587.27|154.55
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AARP [1000]|AARP [100000]|49.07||||49.07||37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AETNA [1015]|AETNA [101529]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AMBETTER [2930]|AMBETTER [293000]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|49.07||||49.07|24.54|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.07||||49.07|35.33|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.07||||49.07|24.54|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.07||||49.07|24.54|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|49.07||||49.07|37.29|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|CIGNA [1260]|CIGNA PPO [126025]|49.07||||49.07|19.63|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|49.07||||49.07||37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|49.07||||49.07|24.54|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|Self-pay|Self-pay|49.07||||49.07|9.81|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|TML [1980]|TML [198000]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.07||||49.07|19.1|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.07||||49.07||37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|UNICARE [2040]|UNICARE [204000]|49.07||||49.07||37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.07||||49.07||37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|WEB TPA [2115]|WEB TPA [211500]|49.07||||49.07|33.86|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.07||||49.07|0|37.29|9.81
117538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CASTOR OIL 100 % ORAL|177 mL|WORKER'S COMP [2125]|TML WC [212537]|49.07||||49.07||37.29|9.81
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|16.82||||16.82||12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.82||||16.82|6.55|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.82||||16.82|8.41|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.82||||16.82|6.55|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
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]|16.82||||16.82|12.11|12.78|3.36
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]|16.82||||16.82|8.41|12.78|3.36
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]|16.82||||16.82|8.41|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.82||||16.82|12.78|12.78|3.36
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]|16.82||||16.82|6.55|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.82||||16.82|11.61|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.82||||16.82|6.73|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.82||||16.82||12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.82||||16.82|11.61|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.82||||16.82|8.41|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.82||||16.82|11.61|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.82||||16.82|0|12.78|3.36
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]|16.82||||16.82|6.55|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.82||||16.82|0|12.78|3.36
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]|16.82||||16.82|6.55|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.82||||16.82|11.61|12.78|3.36
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]|16.82||||16.82|6.55|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|16.82||||16.82|3.36|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|16.82||||16.82|11.61|12.78|3.36
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]|16.82||||16.82|6.55|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.82||||16.82||12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|16.82||||16.82||12.78|3.36
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]|16.82||||16.82||12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.82||||16.82|11.61|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
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]|16.82||||16.82|0|12.78|3.36
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|16.82||||16.82||12.78|3.36
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|109.8||||109.8||83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.8||||109.8|54.9|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.8||||109.8|42.73|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
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]|109.8||||109.8|79.06|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.8||||109.8|54.9|83.45|21.96
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]|109.8||||109.8|54.9|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.8||||109.8|83.45|83.45|21.96
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]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.8||||109.8|75.76|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|109.8||||109.8|43.92|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.8||||109.8||83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|109.8||||109.8|75.76|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.8||||109.8|54.9|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.8||||109.8|75.76|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.8||||109.8|0|83.45|21.96
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]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|109.8||||109.8|75.76|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|109.8||||109.8|21.96|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|109.8||||109.8|75.76|83.45|21.96
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]|109.8||||109.8|42.73|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.8||||109.8||83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|109.8||||109.8||83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.8||||109.8||83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|109.8||||109.8|75.76|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.8||||109.8|0|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|109.8||||109.8||83.45|21.96
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|171.6||||171.6||130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|171.6||||171.6|85.8|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171.6||||171.6|123.55|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171.6||||171.6|85.8|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171.6||||171.6|85.8|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|171.6||||171.6|130.42|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|171.6||||171.6|68.64|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|171.6||||171.6||130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|171.6||||171.6|85.8|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|171.6||||171.6|34.32|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171.6||||171.6|66.79|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171.6||||171.6||130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|171.6||||171.6||130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171.6||||171.6||130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|171.6||||171.6|118.4|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171.6||||171.6|0|130.42|34.32
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|171.6||||171.6||130.42|34.32
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|11.07||||11.07||8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.07||||11.07|4.31|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.07||||11.07|5.54|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.07||||11.07|4.31|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
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]|11.07||||11.07|7.97|8.41|2.21
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]|11.07||||11.07|5.54|8.41|2.21
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]|11.07||||11.07|5.54|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.07||||11.07|8.41|8.41|2.21
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]|11.07||||11.07|4.31|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.07||||11.07|7.64|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.07||||11.07|4.43|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.07||||11.07||8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.07||||11.07|7.64|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.07||||11.07|5.54|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.07||||11.07|7.64|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.07||||11.07|0|8.41|2.21
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]|11.07||||11.07|4.31|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.07||||11.07|0|8.41|2.21
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]|11.07||||11.07|4.31|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.07||||11.07|7.64|8.41|2.21
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]|11.07||||11.07|4.31|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|11.07||||11.07|2.21|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|11.07||||11.07|7.64|8.41|2.21
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]|11.07||||11.07|4.31|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.07||||11.07||8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|11.07||||11.07||8.41|2.21
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]|11.07||||11.07||8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.07||||11.07|7.64|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
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]|11.07||||11.07|0|8.41|2.21
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.07||||11.07||8.41|2.21
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]|142.82||||142.82||108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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|AMBETTER [2930]|AMBETTER [293000]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|142.82||||142.82|71.41|108.54|28.56
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 MEDICAID [1165]|BCBS MEDICAID [116504]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|102.83|108.54|28.56
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]|142.82||||142.82|71.41|108.54|28.56
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]|142.82||||142.82|71.41|108.54|28.56
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 TRADITIONAL OF TEXAS [115503]|142.82||||142.82|108.54|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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 - GREAT WEST [126009]|142.82||||142.82|98.55|108.54|28.56
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 PPO [126025]|142.82||||142.82|57.13|108.54|28.56
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|142.82||||142.82||108.54|28.56
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]|142.82||||142.82|98.55|108.54|28.56
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|142.82||||142.82|71.41|108.54|28.56
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|142.82||||142.82|98.55|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82|98.55|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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|142.82||||142.82|28.56|108.54|28.56
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|TML [1980]|TML [198000]|142.82||||142.82|98.55|108.54|28.56
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]|142.82||||142.82|55.59|108.54|28.56
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]|142.82||||142.82||108.54|28.56
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|UNICARE [2040]|UNICARE [204000]|142.82||||142.82||108.54|28.56
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]|142.82||||142.82||108.54|28.56
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|WEB TPA [2115]|WEB TPA [211500]|142.82||||142.82|98.55|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|142.82||||142.82|0|108.54|28.56
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]|TML WC [212537]|142.82||||142.82||108.54|28.56
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|109.8||||109.8||83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|109.8||||109.8|54.9|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|109.8||||109.8|42.73|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109.8||||109.8|79.06|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109.8||||109.8|54.9|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109.8||||109.8|54.9|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|109.8||||109.8|83.45|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|109.8||||109.8|75.76|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|109.8||||109.8|43.92|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|109.8||||109.8||83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|109.8||||109.8|75.76|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|109.8||||109.8|54.9|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|109.8||||109.8|75.76|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109.8||||109.8|0|83.45|21.96
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]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|109.8||||109.8|75.76|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|Self-pay|Self-pay|109.8||||109.8|21.96|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|109.8||||109.8|75.76|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109.8||||109.8|42.73|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109.8||||109.8||83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|109.8||||109.8||83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109.8||||109.8||83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|109.8||||109.8|75.76|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109.8||||109.8|0|83.45|21.96
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]|109.8||||109.8|0|83.45|21.96
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|109.8||||109.8||83.45|21.96
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AARP [1000]|AARP [100000]|1099.3||||1099.3|549.65|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AETNA [1015]|AETNA [101529]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMBETTER [2930]|AMBETTER [293000]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1099.3||||1099.3|0.14|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|791.5|835.47|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]|1099.3||||1099.3|549.65|835.47|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]|1099.3||||1099.3|549.65|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1099.3||||1099.3|835.47|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1099.3||||1099.3|758.52|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|1099.3||||1099.3|439.72|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1099.3||||1099.3|549.65|835.47|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]|1099.3||||1099.3|758.52|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1099.3||||1099.3|0.14|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1099.3||||1099.3|758.52|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1099.3||||1099.3|758.52|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|Self-pay|Self-pay|1099.3||||1099.3|219.86|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|TML [1980]|TML [198000]|1099.3||||1099.3|758.52|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|549.65|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNICARE [2040]|UNICARE [204000]|1099.3||||1099.3|549.65|835.47|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]|1099.3||||1099.3|549.65|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WEB TPA [2115]|WEB TPA [211500]|1099.3||||1099.3|758.52|835.47|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]|1099.3||||1099.3|0|835.47|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]|1099.3||||1099.3|0|835.47|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|1099.3||||1099.3|549.65|835.47|0.14
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AARP [1000]|AARP [100000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AETNA [1015]|AETNA [101529]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AMBETTER [2930]|AMBETTER [293000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9629||||9629||1925.8|1925.8
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]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA PPO [126025]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9629||||9629||1925.8|1925.8
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]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9629||||9629||1925.8|1925.8
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]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|Self-pay|Self-pay|9629||||9629|1925.8|1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|TML [1980]|TML [198000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UNICARE [2040]|UNICARE [204000]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|WEB TPA [2115]|WEB TPA [211500]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9629||||9629||1925.8|1925.8
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]|9629||||9629||1925.8|1925.8
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|WORKER'S COMP [2125]|TML WC [212537]|9629||||9629||1925.8|1925.8
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.91||||7.91||6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.91||||7.91|3.96|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.91||||7.91|3.08|6.01|1.58
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]|7.91||||7.91|0|6.01|1.58
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]|7.91||||7.91|5.7|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.91||||7.91|3.96|6.01|1.58
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]|7.91||||7.91|3.96|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.91||||7.91|6.01|6.01|1.58
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]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.91||||7.91|5.46|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.91||||7.91|3.16|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.91||||7.91||6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.91||||7.91|5.46|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.91||||7.91|3.96|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.91||||7.91|5.46|6.01|1.58
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]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.91||||7.91|0|6.01|1.58
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]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.91||||7.91|5.46|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|7.91||||7.91|1.58|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.91||||7.91|5.46|6.01|1.58
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]|7.91||||7.91|3.08|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.91||||7.91||6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.91||||7.91||6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.91||||7.91||6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.91||||7.91|5.46|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.91||||7.91|0|6.01|1.58
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]|7.91||||7.91|0|6.01|1.58
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.91||||7.91||6.01|1.58
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.2||||244.2|175.82|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.2||||244.2|175.82|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244.2||||244.2|185.59|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244.2||||244.2|185.59|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|244.2||||244.2|97.68|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|244.2||||244.2|97.68|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244.2||||244.2|122.1|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|244.2||||244.2|48.84|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|244.2||||244.2|48.84|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.2||||244.2|95.04|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|244.2||||244.2|168.5|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.2||||244.2|0|185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|244.2||||244.2||185.59|48.84
121237|ERX|0250 - PHARMACY-GENERAL|ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|244.2||||244.2||185.59|48.84
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|32.01||||32.01||24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|32.01||||32.01|0.62|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.01||||32.01|23.05|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.01||||32.01|16.01|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.01||||32.01|16.01|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|32.01||||32.01|24.33|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|32.01||||32.01|12.8|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|32.01||||32.01||24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|32.01||||32.01|0.62|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|32.01||||32.01|6.4|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.01||||32.01|12.46|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.01||||32.01||24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|32.01||||32.01||24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.01||||32.01||24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|32.01||||32.01|22.09|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.01||||32.01|0|24.33|0.62
121440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 0.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|32.01||||32.01||24.33|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|64.04||||64.04||48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.04||||64.04|0.62|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.04||||64.04|46.11|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.04||||64.04|32.02|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.04||||64.04|32.02|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.04||||64.04|48.67|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|64.04||||64.04|25.62|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.04||||64.04||48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.04||||64.04|0.62|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|64.04||||64.04|12.81|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.04||||64.04|24.92|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.04||||64.04||48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|64.04||||64.04||48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.04||||64.04||48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|64.04||||64.04|44.19|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.04||||64.04|0|48.67|0.62
121469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XL 1 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|64.04||||64.04||48.67|0.62
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|3.83||||3.83||2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.83||||3.83|1.92|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.83||||3.83|2.76|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.83||||3.83|1.92|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.83||||3.83|1.92|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.83||||3.83|2.91|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|3.83||||3.83|1.53|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.83||||3.83||2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.83||||3.83|1.92|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|Self-pay|Self-pay|3.83||||3.83|0.77|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|TML [1980]|TML [198000]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.83||||3.83|1.49|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.83||||3.83||2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|3.83||||3.83||2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.83||||3.83||2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|3.83||||3.83|2.64|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.83||||3.83|0|2.91|0.77
121604|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|3.83||||3.83||2.91|0.77
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AARP [1000]|AARP [100000]|699.6||||699.6||531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AMBETTER [2930]|AMBETTER [293000]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|699.6||||699.6|349.8|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|699.6||||699.6|503.71|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|699.6||||699.6|349.8|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|699.6||||699.6|349.8|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|699.6||||699.6|531.7|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA PPO [126025]|699.6||||699.6|279.84|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|699.6||||699.6||531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|699.6||||699.6|349.8|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|Self-pay|Self-pay|699.6||||699.6|139.92|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|TML [1980]|TML [198000]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|699.6||||699.6|272.28|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|699.6||||699.6||531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|UNICARE [2040]|UNICARE [204000]|699.6||||699.6||531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|699.6||||699.6||531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|WEB TPA [2115]|WEB TPA [211500]|699.6||||699.6|482.72|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|699.6||||699.6|0|531.7|139.92
121673|ERX|0250 - PHARMACY-GENERAL|PLASMA PROTEIN FRACTION 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TML WC [212537]|699.6||||699.6||531.7|139.92
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AARP [1000]|AARP [100000]|567.6||||567.6||431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AETNA [1015]|AETNA [101529]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AMBETTER [2930]|AMBETTER [293000]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|567.6||||567.6|283.8|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|567.6||||567.6|408.67|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|567.6||||567.6|283.8|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|567.6||||567.6|283.8|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|567.6||||567.6|431.38|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|CIGNA [1260]|CIGNA PPO [126025]|567.6||||567.6|227.04|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|567.6||||567.6||431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|567.6||||567.6|283.8|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|Self-pay|Self-pay|567.6||||567.6|113.52|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|TML [1980]|TML [198000]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|567.6||||567.6|220.91|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|567.6||||567.6||431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|UNICARE [2040]|UNICARE [204000]|567.6||||567.6||431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|567.6||||567.6||431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|WEB TPA [2115]|WEB TPA [211500]|567.6||||567.6|391.64|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|567.6||||567.6|0|431.38|113.52
121731|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|50 mL|WORKER'S COMP [2125]|TML WC [212537]|567.6||||567.6||431.38|113.52
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|199.98||||199.98||151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|199.98||||199.98|78|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|199.98||||199.98|143.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|199.98||||199.98|99.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|199.98||||199.98|99.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|199.98||||199.98|151.98|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|199.98||||199.98|79.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|199.98||||199.98||151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|199.98||||199.98|78|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|199.98||||199.98|40|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|TML [1980]|TML [198000]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|199.98||||199.98|77.83|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|199.98||||199.98||151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|199.98||||199.98||151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|199.98||||199.98||151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|199.98||||199.98|137.99|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|199.98||||199.98|0|151.98|40
121739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PARICALCITOL 5 MCG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|199.98||||199.98||151.98|40
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|25.41||||25.41||19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMBETTER [2930]|AMBETTER [293000]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMBETTER [2930]|AMBETTER [293000]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.41||||25.41|12.71|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.41||||25.41|12.71|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.41||||25.41|9.89|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|18.3|19.31|5.08
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]|25.41||||25.41|18.3|19.31|5.08
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]|25.41||||25.41|12.71|19.31|5.08
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]|25.41||||25.41|12.71|19.31|5.08
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]|25.41||||25.41|12.71|19.31|5.08
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]|25.41||||25.41|12.71|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.41||||25.41|19.31|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.41||||25.41|19.31|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|25.41||||25.41|10.16|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|25.41||||25.41|10.16|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.41||||25.41||19.31|5.08
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]|25.41||||25.41|17.53|19.31|5.08
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]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.41||||25.41|12.71|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.41||||25.41|12.71|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.41||||25.41|17.53|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.41||||25.41|17.53|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|25.41||||25.41|5.08|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|25.41||||25.41|5.08|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|TML [1980]|TML [198000]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|TML [1980]|TML [198000]|25.41||||25.41|17.53|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41|9.89|19.31|5.08
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]|25.41||||25.41||19.31|5.08
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]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNICARE [2040]|UNICARE [204000]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNICARE [2040]|UNICARE [204000]|25.41||||25.41||19.31|5.08
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]|25.41||||25.41||19.31|5.08
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]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WEB TPA [2115]|WEB TPA [211500]|25.41||||25.41|17.53|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WEB TPA [2115]|WEB TPA [211500]|25.41||||25.41|17.53|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
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]|25.41||||25.41|0|19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|25.41||||25.41||19.31|5.08
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|25.41||||25.41||19.31|5.08
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]|72.6||||72.6||55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72.6||||72.6|6.42|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|52.27|55.18|6.42
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]|72.6||||72.6|36.3|55.18|6.42
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]|72.6||||72.6|36.3|55.18|6.42
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 TRADITIONAL OF TEXAS [115503]|72.6||||72.6|55.18|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|72.6||||72.6|50.09|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|72.6||||72.6|29.04|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72.6||||72.6||55.18|6.42
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]|72.6||||72.6|50.09|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72.6||||72.6|6.42|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72.6||||72.6|50.09|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6|50.09|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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|72.6||||72.6|14.52|55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|72.6||||72.6|50.09|55.18|6.42
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]|72.6||||72.6|28.26|55.18|6.42
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]|72.6||||72.6||55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|72.6||||72.6||55.18|6.42
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]|72.6||||72.6||55.18|6.42
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|72.6||||72.6|50.09|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|72.6||||72.6|0|55.18|6.42
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]|TML WC [212537]|72.6||||72.6||55.18|6.42
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|6.47||||6.47||4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.47||||6.47|3.24|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.47||||6.47|4.66|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.47||||6.47|3.24|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.47||||6.47|3.24|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.47||||6.47|4.92|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.47||||6.47|2.59|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.47||||6.47||4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.47||||6.47|3.24|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|6.47||||6.47|1.29|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.47||||6.47|2.52|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.47||||6.47||4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|6.47||||6.47||4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.47||||6.47||4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.47||||6.47|4.46|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.47||||6.47|0|4.92|1.29
12185|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.47||||6.47||4.92|1.29
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|248.82||||248.82||189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|248.82||||248.82|124.41|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248.82||||248.82|179.15|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248.82||||248.82|124.41|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248.82||||248.82|124.41|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|248.82||||248.82|189.1|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|248.82||||248.82|99.53|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|248.82||||248.82||189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|248.82||||248.82|124.41|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|248.82||||248.82|49.76|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248.82||||248.82|96.84|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248.82||||248.82||189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|248.82||||248.82||189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248.82||||248.82||189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|248.82||||248.82|171.69|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248.82||||248.82|0|189.1|49.76
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|248.82||||248.82||189.1|49.76
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|133.46||||133.46||101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|133.46||||133.46|66.73|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|133.46||||133.46|51.94|101.43|26.69
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]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133.46||||133.46|96.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133.46||||133.46|66.73|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133.46||||133.46|66.73|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|133.46||||133.46|101.43|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|133.46||||133.46|92.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|133.46||||133.46|53.38|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|133.46||||133.46||101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|133.46||||133.46|92.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|133.46||||133.46|66.73|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|133.46||||133.46|92.09|101.43|26.69
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]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133.46||||133.46|0|101.43|26.69
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]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|133.46||||133.46|92.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|133.46||||133.46|26.69|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|133.46||||133.46|92.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133.46||||133.46|51.94|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133.46||||133.46||101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|133.46||||133.46||101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133.46||||133.46||101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|133.46||||133.46|92.09|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133.46||||133.46|0|101.43|26.69
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]|133.46||||133.46|0|101.43|26.69
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|133.46||||133.46||101.43|26.69
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|4.29||||4.29||3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.29||||4.29|2.15|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.29||||4.29|1.67|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|3.09|3.26|0.86
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]|4.29||||4.29|2.15|3.26|0.86
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]|4.29||||4.29|2.15|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.29||||4.29|3.26|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.29||||4.29|2.96|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|4.29||||4.29|1.72|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.29||||4.29||3.26|0.86
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]|4.29||||4.29|2.96|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.29||||4.29|2.15|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.29||||4.29|2.96|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.29||||4.29|2.96|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|4.29||||4.29|0.86|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|4.29||||4.29|2.96|3.26|0.86
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]|4.29||||4.29|1.67|3.26|0.86
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]|4.29||||4.29||3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|4.29||||4.29||3.26|0.86
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]|4.29||||4.29||3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|4.29||||4.29|2.96|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
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]|4.29||||4.29|0|3.26|0.86
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|4.29||||4.29||3.26|0.86
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AARP [1000]|AARP [100000]|1.1||||1.1||0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.1||||1.1|0.55|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.1||||1.1|0.79|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.1||||1.1|0.55|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.1||||1.1|0.55|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.1||||1.1|0.84|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.1||||1.1|0.44|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.1||||1.1||0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.1||||1.1|0.55|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|Self-pay|Self-pay|1.1||||1.1|0.22|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|TML [1980]|TML [198000]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.1||||1.1|0.43|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.1||||1.1||0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.1||||1.1||0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.1||||1.1||0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.1||||1.1|0.76|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.1||||1.1|0|0.84|0.22
121986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.1||||1.1||0.84|0.22
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.07||||8.07||6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.07||||8.07|4.04|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.07||||8.07|3.14|6.13|1.61
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]|8.07||||8.07|0|6.13|1.61
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]|8.07||||8.07|5.81|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.07||||8.07|4.04|6.13|1.61
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]|8.07||||8.07|4.04|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.07||||8.07|6.13|6.13|1.61
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]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.07||||8.07|5.57|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.07||||8.07|3.23|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.07||||8.07||6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.07||||8.07|5.57|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.07||||8.07|4.04|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.07||||8.07|5.57|6.13|1.61
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]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.07||||8.07|0|6.13|1.61
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]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.07||||8.07|5.57|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|Self-pay|Self-pay|8.07||||8.07|1.61|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.07||||8.07|5.57|6.13|1.61
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]|8.07||||8.07|3.14|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.07||||8.07||6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.07||||8.07||6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.07||||8.07||6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.07||||8.07|5.57|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.07||||8.07|0|6.13|1.61
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]|8.07||||8.07|0|6.13|1.61
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.07||||8.07||6.13|1.61
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|1516.95||||1516.95||1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1516.95||||1516.95|758.48|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1516.95||||1516.95|590.4|1152.88|303.39
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]|1516.95||||1516.95|0|1152.88|303.39
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]|1516.95||||1516.95|1092.2|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1516.95||||1516.95|758.48|1152.88|303.39
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]|1516.95||||1516.95|758.48|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1516.95||||1516.95|1152.88|1152.88|303.39
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]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1516.95||||1516.95|1046.7|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1516.95||||1516.95|606.78|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1516.95||||1516.95||1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1516.95||||1516.95|1046.7|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1516.95||||1516.95|758.48|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1516.95||||1516.95|1046.7|1152.88|303.39
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]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1516.95||||1516.95|0|1152.88|303.39
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]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1516.95||||1516.95|1046.7|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|1516.95||||1516.95|303.39|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|TML [1980]|TML [198000]|1516.95||||1516.95|1046.7|1152.88|303.39
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]|1516.95||||1516.95|590.4|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1516.95||||1516.95||1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNICARE [2040]|UNICARE [204000]|1516.95||||1516.95||1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1516.95||||1516.95||1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|1516.95||||1516.95|1046.7|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1516.95||||1516.95|0|1152.88|303.39
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]|1516.95||||1516.95|0|1152.88|303.39
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1516.95||||1516.95||1152.88|303.39
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AARP [1000]|AARP [100000]|145.2||||145.2||110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|104.54|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|72.6|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|72.6|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|110.35|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2||110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|Self-pay|Self-pay|145.2||||145.2|29.04|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|TML [1980]|TML [198000]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|56.51|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2||110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|145.2||||145.2||110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2||110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2|0|110.35|29.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2||110.35|29.04
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AARP [1000]|AARP [100000]|89.1||||89.1||67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AETNA [1015]|AETNA [101529]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.1||||89.1|44.55|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.1||||89.1|64.15|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.1||||89.1|44.55|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.1||||89.1|44.55|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|89.1||||89.1|67.72|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|89.1||||89.1|35.64|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.1||||89.1||67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.1||||89.1|44.55|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|Self-pay|Self-pay|89.1||||89.1|17.82|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|TML [1980]|TML [198000]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.1||||89.1|34.68|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.1||||89.1||67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|89.1||||89.1||67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.1||||89.1||67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|89.1||||89.1|61.48|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89.1||||89.1|0|67.72|17.82
12218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 5 GRAM ORAL PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|89.1||||89.1||67.72|17.82
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|82.5||||82.5|41.25|112.76|2.28
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]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82.5||||82.5|32.11|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82.5||||82.5|2.28|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82.5||||82.5|32.11|112.76|2.28
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]|82.5||||82.5|0|112.76|2.28
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]|82.5||||82.5|59.4|112.76|2.28
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]|82.5||||82.5|41.25|112.76|2.28
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]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82.5||||82.5|62.7|112.76|2.28
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]|82.5||||82.5|32.11|112.76|2.28
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]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82.5||||82.5|56.93|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|82.5||||82.5|33|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|82.5||||82.5|56.93|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82.5||||82.5|2.28|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.5||||82.5|56.93|112.76|2.28
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]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82.5||||82.5|32.11|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82.5||||82.5|0|112.76|2.28
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]|82.5||||82.5|32.11|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|82.5||||82.5|56.93|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82.5||||82.5|32.11|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|82.5||||82.5|16.5|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|82.5||||82.5|56.93|112.76|2.28
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]|82.5||||82.5|32.11|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|82.5||||82.5|56.93|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82.5||||82.5|0|112.76|2.28
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]|82.5||||82.5|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|82.5||||82.5|41.25|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|148.37||||148.37|2.28|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|148.37||||148.37|106.83|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|148.37||||148.37|112.76|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|148.37||||148.37|59.35|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|148.37||||148.37|2.28|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|148.37||||148.37|29.67|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|148.37||||148.37|57.75|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|148.37||||148.37|74.19|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|148.37||||148.37|102.38|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|148.37||||148.37|0|112.76|2.28
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|148.37||||148.37|74.19|112.76|2.28
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|21.78||||21.78||16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.78||||21.78|10.89|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.78||||21.78|15.68|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.78||||21.78|10.89|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.78||||21.78|10.89|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.78||||21.78|16.55|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|21.78||||21.78|8.71|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.78||||21.78||16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.78||||21.78|10.89|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|Self-pay|Self-pay|21.78||||21.78|4.36|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.78||||21.78|8.48|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.78||||21.78||16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|21.78||||21.78||16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.78||||21.78||16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|21.78||||21.78|15.03|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.78||||21.78|0|16.55|4.36
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|21.78||||21.78||16.55|4.36
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|237.6||||237.6||180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.6||||237.6|118.8|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.6||||237.6|171.07|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.6||||237.6|118.8|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.6||||237.6|118.8|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.6||||237.6|180.58|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|237.6||||237.6|95.04|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.6||||237.6||180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.6||||237.6|118.8|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|237.6||||237.6|47.52|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.6||||237.6|92.47|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.6||||237.6||180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|237.6||||237.6||180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.6||||237.6||180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|237.6||||237.6|163.94|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.6||||237.6|0|180.58|47.52
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]|237.6||||237.6|0|180.58|47.52
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|237.6||||237.6||180.58|47.52
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AARP [1000]|AARP [100000]|77.17||||77.17||58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AETNA [1015]|AETNA [101529]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMBETTER [2930]|AMBETTER [293000]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.17||||77.17|30.03|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|77.17||||77.17|2.47|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|77.17||||77.17|30.03|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
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]|77.17||||77.17|55.56|58.65|2.47
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]|77.17||||77.17|38.59|58.65|2.47
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]|77.17||||77.17|38.59|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|77.17||||77.17|58.65|58.65|2.47
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]|77.17||||77.17|30.03|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|77.17||||77.17|53.25|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA PPO [126025]|77.17||||77.17|30.87|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|77.17||||77.17||58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|77.17||||77.17|53.25|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|77.17||||77.17|2.47|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|77.17||||77.17|53.25|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.17||||77.17|0|58.65|2.47
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]|77.17||||77.17|30.03|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.17||||77.17|0|58.65|2.47
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]|77.17||||77.17|30.03|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|77.17||||77.17|53.25|58.65|2.47
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]|77.17||||77.17|30.03|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|Self-pay|Self-pay|77.17||||77.17|15.43|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|TML [1980]|TML [198000]|77.17||||77.17|53.25|58.65|2.47
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]|77.17||||77.17|30.03|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.17||||77.17||58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNICARE [2040]|UNICARE [204000]|77.17||||77.17||58.65|2.47
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]|77.17||||77.17||58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WEB TPA [2115]|WEB TPA [211500]|77.17||||77.17|53.25|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
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]|77.17||||77.17|0|58.65|2.47
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WORKER'S COMP [2125]|TML WC [212537]|77.17||||77.17||58.65|2.47
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]|58.57||||58.57||44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|58.57||||58.57|29.29|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|42.17|44.51|11.71
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]|58.57||||58.57|29.29|44.51|11.71
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]|58.57||||58.57|29.29|44.51|11.71
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 TRADITIONAL OF TEXAS [115503]|58.57||||58.57|44.51|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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 - GREAT WEST [126009]|58.57||||58.57|40.41|44.51|11.71
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 PPO [126025]|58.57||||58.57|23.43|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|58.57||||58.57||44.51|11.71
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]|58.57||||58.57|40.41|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|58.57||||58.57|29.29|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58.57||||58.57|40.41|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57|40.41|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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|58.57||||58.57|11.71|44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|58.57||||58.57|40.41|44.51|11.71
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]|58.57||||58.57|22.8|44.51|11.71
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]|58.57||||58.57||44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|58.57||||58.57||44.51|11.71
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]|58.57||||58.57||44.51|11.71
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|58.57||||58.57|40.41|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|58.57||||58.57|0|44.51|11.71
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]|TML WC [212537]|58.57||||58.57||44.51|11.71
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]|112.03||||112.03||85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|112.03||||112.03|56.02|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|80.66|85.14|22.41
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]|112.03||||112.03|56.02|85.14|22.41
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]|112.03||||112.03|56.02|85.14|22.41
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 TRADITIONAL OF TEXAS [115503]|112.03||||112.03|85.14|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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 - GREAT WEST [126009]|112.03||||112.03|77.3|85.14|22.41
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 PPO [126025]|112.03||||112.03|44.81|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|112.03||||112.03||85.14|22.41
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]|112.03||||112.03|77.3|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|112.03||||112.03|56.02|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|112.03||||112.03|77.3|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03|77.3|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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|112.03||||112.03|22.41|85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|112.03||||112.03|77.3|85.14|22.41
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]|112.03||||112.03|43.6|85.14|22.41
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]|112.03||||112.03||85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|112.03||||112.03||85.14|22.41
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]|112.03||||112.03||85.14|22.41
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|112.03||||112.03|77.3|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|112.03||||112.03|0|85.14|22.41
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]|TML WC [212537]|112.03||||112.03||85.14|22.41
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|2.5||||2.5||1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.5||||2.5|1.25|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.5||||2.5|1.8|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.5||||2.5|1.25|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.5||||2.5|1.25|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.5||||2.5|1.9|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.5||||2.5|1|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.5||||2.5||1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.5||||2.5|1.25|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|2.5||||2.5|0.5|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.5||||2.5|0.97|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.5||||2.5||1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.5||||2.5||1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.5||||2.5||1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.5||||2.5|1.73|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.5||||2.5|0|1.9|0.5
122398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 9,000 UNIT CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.5||||2.5||1.9|0.5
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AARP [1000]|AARP [100000]|158.4||||158.4||120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|61.65|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|114.05|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|79.2|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|79.2|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|120.38|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4||120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|Self-pay|Self-pay|158.4||||158.4|31.68|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|61.65|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4||120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4||120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4||120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4|0|120.38|31.68
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]|158.4||||158.4|0|120.38|31.68
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4||120.38|31.68
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|211.2||||211.2||160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|211.2||||211.2|105.6|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211.2||||211.2|152.06|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211.2||||211.2|105.6|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211.2||||211.2|105.6|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|211.2||||211.2|160.51|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|211.2||||211.2|84.48|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|211.2||||211.2||160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|211.2||||211.2|105.6|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|211.2||||211.2|42.24|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211.2||||211.2|82.2|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211.2||||211.2||160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|211.2||||211.2||160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211.2||||211.2||160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|211.2||||211.2|145.73|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211.2||||211.2|0|160.51|42.24
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|211.2||||211.2||160.51|42.24
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|26.27||||26.27|13.14|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|0|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|26.27||||26.27|0|19.97|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]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|0|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.27||||26.27|0.03|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|18.91|19.97|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]|26.27||||26.27|13.14|19.97|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]|26.27||||26.27|13.14|19.97|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 TRADITIONAL OF TEXAS [115503]|26.27||||26.27|19.97|19.97|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]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|0|19.97|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 - GREAT WEST [126009]|26.27||||26.27|18.13|19.97|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 PPO [126025]|26.27||||26.27|10.51|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.27||||26.27|13.14|19.97|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]|26.27||||26.27|18.13|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.27||||26.27|0.03|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.27||||26.27|18.13|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|18.13|19.97|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]|26.27||||26.27|10.22|19.97|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|26.27||||26.27|5.25|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|26.27||||26.27|18.13|19.97|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]|26.27||||26.27|10.22|19.97|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]|26.27||||26.27|13.14|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|26.27||||26.27|13.14|19.97|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]|26.27||||26.27|13.14|19.97|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|26.27||||26.27|18.13|19.97|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]|26.27||||26.27|0|19.97|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]|26.27||||26.27|0|19.97|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]|TML WC [212537]|26.27||||26.27|13.14|19.97|0.03
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|336.87||||336.87||256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.87||||336.87|168.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.87||||336.87|242.55|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.87||||336.87|168.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.87||||336.87|168.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.87||||336.87|256.02|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|336.87||||336.87|134.75|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.87||||336.87||256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.87||||336.87|168.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|336.87||||336.87|67.37|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.87||||336.87|131.11|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.87||||336.87||256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|336.87||||336.87||256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.87||||336.87||256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|336.87||||336.87|232.44|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.87||||336.87|0|256.02|67.37
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]|336.87||||336.87|0|256.02|67.37
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|336.87||||336.87||256.02|67.37
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AARP [1000]|AARP [100000]|27.08||||27.08||20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AETNA [1015]|AETNA [101529]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.08||||27.08|13.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.08||||27.08|19.5|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.08||||27.08|13.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.08||||27.08|13.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.08||||27.08|20.58|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|27.08||||27.08|10.83|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.08||||27.08||20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.08||||27.08|13.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|Self-pay|Self-pay|27.08||||27.08|5.42|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|TML [1980]|TML [198000]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.08||||27.08|10.54|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.08||||27.08||20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|27.08||||27.08||20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.08||||27.08||20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|27.08||||27.08|18.69|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.08||||27.08|0|20.58|5.42
123751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|27.08||||27.08||20.58|5.42
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AARP [1000]|AARP [100000]|63.09||||63.09||47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AETNA [1015]|AETNA [101529]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMBETTER [2930]|AMBETTER [293000]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.09||||63.09|24.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|63.09||||63.09|31.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|63.09||||63.09|24.55|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
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]|63.09||||63.09|45.42|47.95|12.62
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]|63.09||||63.09|31.55|47.95|12.62
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]|63.09||||63.09|31.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|63.09||||63.09|47.95|47.95|12.62
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]|63.09||||63.09|24.55|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|63.09||||63.09|43.53|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA [1260]|CIGNA PPO [126025]|63.09||||63.09|25.24|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|63.09||||63.09||47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|63.09||||63.09|43.53|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|63.09||||63.09|31.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.09||||63.09|43.53|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.09||||63.09|0|47.95|12.62
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]|63.09||||63.09|24.55|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.09||||63.09|0|47.95|12.62
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]|63.09||||63.09|24.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|63.09||||63.09|43.53|47.95|12.62
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]|63.09||||63.09|24.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|Self-pay|Self-pay|63.09||||63.09|12.62|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|TML [1980]|TML [198000]|63.09||||63.09|43.53|47.95|12.62
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]|63.09||||63.09|24.55|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.09||||63.09||47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNICARE [2040]|UNICARE [204000]|63.09||||63.09||47.95|12.62
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]|63.09||||63.09||47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WEB TPA [2115]|WEB TPA [211500]|63.09||||63.09|43.53|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
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]|63.09||||63.09|0|47.95|12.62
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WORKER'S COMP [2125]|TML WC [212537]|63.09||||63.09||47.95|12.62
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AARP [1000]|AARP [100000]|51.93||||51.93||39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AETNA [1015]|AETNA [101529]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMBETTER [2930]|AMBETTER [293000]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.93||||51.93|25.97|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.93||||51.93|37.39|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.93||||51.93|25.97|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.93||||51.93|25.97|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.93||||51.93|39.47|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|CIGNA [1260]|CIGNA PPO [126025]|51.93||||51.93|20.77|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.93||||51.93||39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.93||||51.93|25.97|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|Self-pay|Self-pay|51.93||||51.93|10.39|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|TML [1980]|TML [198000]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.93||||51.93|20.21|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.93||||51.93||39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UNICARE [2040]|UNICARE [204000]|51.93||||51.93||39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.93||||51.93||39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WEB TPA [2115]|WEB TPA [211500]|51.93||||51.93|35.83|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.93||||51.93|0|39.47|10.39
124131|ERX|0250 - PHARMACY-GENERAL|BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT|14.2 g|WORKER'S COMP [2125]|TML WC [212537]|51.93||||51.93||39.47|10.39
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|153.78||||153.78||116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|153.78||||153.78|76.89|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|153.78||||153.78|59.85|116.87|30.76
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]|153.78||||153.78|0|116.87|30.76
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]|153.78||||153.78|110.72|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|153.78||||153.78|76.89|116.87|30.76
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]|153.78||||153.78|76.89|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|153.78||||153.78|116.87|116.87|30.76
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]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|153.78||||153.78|106.11|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|153.78||||153.78|61.51|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|153.78||||153.78||116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|153.78||||153.78|106.11|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|153.78||||153.78|76.89|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|153.78||||153.78|106.11|116.87|30.76
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]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|153.78||||153.78|0|116.87|30.76
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]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|153.78||||153.78|106.11|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|153.78||||153.78|30.76|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|153.78||||153.78|106.11|116.87|30.76
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]|153.78||||153.78|59.85|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|153.78||||153.78||116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|153.78||||153.78||116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|153.78||||153.78||116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|153.78||||153.78|106.11|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|153.78||||153.78|0|116.87|30.76
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]|153.78||||153.78|0|116.87|30.76
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|153.78||||153.78||116.87|30.76
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|3298.16||||3298.16||2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3298.16||||3298.16|0.6|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3298.16||||3298.16|2374.68|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3298.16||||3298.16|1649.08|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3298.16||||3298.16|1649.08|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3298.16||||3298.16|2506.6|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|3298.16||||3298.16|1319.26|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3298.16||||3298.16||2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3298.16||||3298.16|0.6|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|Self-pay|Self-pay|3298.16||||3298.16|659.63|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|TML [1980]|TML [198000]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3298.16||||3298.16|1283.64|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3298.16||||3298.16||2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|3298.16||||3298.16||2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3298.16||||3298.16||2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|3298.16||||3298.16|2275.73|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3298.16||||3298.16|0|2506.6|0.6
124716|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|3298.16||||3298.16||2506.6|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|5278.56||||5278.56||4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMBETTER [2930]|AMBETTER [293000]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5278.56||||5278.56|0.6|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5278.56||||5278.56|3800.56|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5278.56||||5278.56|2639.28|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5278.56||||5278.56|2639.28|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5278.56||||5278.56|4011.71|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA PPO [126025]|5278.56||||5278.56|2639.28|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5278.56||||5278.56||4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5278.56||||5278.56|0.6|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|5278.56||||5278.56|1055.71|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TML [1980]|TML [198000]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5278.56||||5278.56|2054.42|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5278.56||||5278.56||4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNICARE [2040]|UNICARE [204000]|5278.56||||5278.56||4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5278.56||||5278.56||4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WEB TPA [2115]|WEB TPA [211500]|5278.56||||5278.56|3642.21|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5278.56||||5278.56|0|4011.71|0.6
124717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TML WC [212537]|5278.56||||5278.56||4011.71|0.6
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|11.88||||11.88||9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.88||||11.88|5.94|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.88||||11.88|4.62|9.03|2.38
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]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.88||||11.88|8.55|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.88||||11.88|5.94|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.88||||11.88|5.94|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.88||||11.88|9.03|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.88||||11.88|8.2|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|11.88||||11.88|4.75|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.88||||11.88||9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.88||||11.88|8.2|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.88||||11.88|5.94|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.88||||11.88|8.2|9.03|2.38
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]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.88||||11.88|0|9.03|2.38
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]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.88||||11.88|8.2|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|11.88||||11.88|2.38|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|11.88||||11.88|8.2|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.88||||11.88|4.62|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.88||||11.88||9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|11.88||||11.88||9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.88||||11.88||9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|11.88||||11.88|8.2|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.88||||11.88|0|9.03|2.38
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]|11.88||||11.88|0|9.03|2.38
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|11.88||||11.88||9.03|2.38
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|234.45||||234.45||178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|234.45||||234.45|117.23|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234.45||||234.45|168.8|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234.45||||234.45|117.23|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234.45||||234.45|117.23|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|234.45||||234.45|178.18|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|234.45||||234.45|93.78|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|234.45||||234.45||178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|234.45||||234.45|117.23|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|234.45||||234.45|46.89|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234.45||||234.45|91.25|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234.45||||234.45||178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|234.45||||234.45||178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234.45||||234.45||178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|234.45||||234.45|161.77|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234.45||||234.45|0|178.18|46.89
125074|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|234.45||||234.45|117.23|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234.45||||234.45|168.8|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234.45||||234.45|117.23|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234.45||||234.45|117.23|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|234.45||||234.45|178.18|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|234.45||||234.45|93.78|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|234.45||||234.45|117.23|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|234.45||||234.45|46.89|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234.45||||234.45|91.25|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234.45||||234.45||178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|234.45||||234.45|161.77|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234.45||||234.45|0|178.18|46.89
125075|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|234.45||||234.45||178.18|46.89
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AARP [1000]|AARP [100000]|156.42||||156.42||118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AETNA [1015]|AETNA [101529]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AMBETTER [2930]|AMBETTER [293000]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|156.42||||156.42|78.21|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156.42||||156.42|112.62|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156.42||||156.42|78.21|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156.42||||156.42|78.21|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|156.42||||156.42|118.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|CIGNA [1260]|CIGNA PPO [126025]|156.42||||156.42|62.57|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|156.42||||156.42||118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|156.42||||156.42|78.21|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|Self-pay|Self-pay|156.42||||156.42|31.28|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|TML [1980]|TML [198000]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156.42||||156.42|60.88|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156.42||||156.42||118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|UNICARE [2040]|UNICARE [204000]|156.42||||156.42||118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156.42||||156.42||118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|WEB TPA [2115]|WEB TPA [211500]|156.42||||156.42|107.93|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156.42||||156.42|0|118.88|31.28
125247|ERX|0250 - PHARMACY-GENERAL|SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP|237 mL|WORKER'S COMP [2125]|TML WC [212537]|156.42||||156.42||118.88|31.28
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|2829.57||||2829.57||2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2829.57||||2829.57|1414.79|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2829.57||||2829.57|2037.29|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2829.57||||2829.57|1414.79|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2829.57||||2829.57|1414.79|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2829.57||||2829.57|2150.47|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|2829.57||||2829.57|1131.83|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2829.57||||2829.57||2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2829.57||||2829.57|1414.79|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|Self-pay|Self-pay|2829.57||||2829.57|565.91|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2829.57||||2829.57|1101.27|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2829.57||||2829.57||2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|2829.57||||2829.57||2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2829.57||||2829.57||2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|2829.57||||2829.57|1952.4|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2829.57||||2829.57|0|2150.47|565.91
125508|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 0.3 % EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|2829.57||||2829.57||2150.47|565.91
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AARP [1000]|AARP [100000]|26.93||||26.93||20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AETNA [1015]|AETNA [101529]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AMBETTER [2930]|AMBETTER [293000]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.93||||26.93|13.47|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.93||||26.93|19.39|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.93||||26.93|13.47|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.93||||26.93|13.47|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.93||||26.93|20.47|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|CIGNA [1260]|CIGNA PPO [126025]|26.93||||26.93|10.77|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.93||||26.93||20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.93||||26.93|13.47|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|Self-pay|Self-pay|26.93||||26.93|5.39|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|TML [1980]|TML [198000]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.93||||26.93|10.48|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.93||||26.93||20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|UNICARE [2040]|UNICARE [204000]|26.93||||26.93||20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.93||||26.93||20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|WEB TPA [2115]|WEB TPA [211500]|26.93||||26.93|18.58|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.93||||26.93|0|20.47|5.39
125684|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS|1 each|WORKER'S COMP [2125]|TML WC [212537]|26.93||||26.93||20.47|5.39
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AARP [1000]|AARP [100000]|69.96||||69.96|34.98|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA [1015]|AETNA [101529]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMBETTER [2930]|AMBETTER [293000]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69.96||||69.96|0.88|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69.96||||69.96|27.23|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|50.37|53.17|0.88
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]|69.96||||69.96|34.98|53.17|0.88
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]|69.96||||69.96|34.98|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69.96||||69.96|53.17|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69.96||||69.96|48.27|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA PPO [126025]|69.96||||69.96|27.98|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69.96||||69.96|34.98|53.17|0.88
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]|69.96||||69.96|48.27|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69.96||||69.96|0.88|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69.96||||69.96|48.27|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.96||||69.96|48.27|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|Self-pay|Self-pay|69.96||||69.96|13.99|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|TML [1980]|TML [198000]|69.96||||69.96|48.27|53.17|0.88
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]|69.96||||69.96|27.23|53.17|0.88
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]|69.96||||69.96|34.98|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNICARE [2040]|UNICARE [204000]|69.96||||69.96|34.98|53.17|0.88
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]|69.96||||69.96|34.98|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WEB TPA [2115]|WEB TPA [211500]|69.96||||69.96|48.27|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
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]|69.96||||69.96|0|53.17|0.88
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WORKER'S COMP [2125]|TML WC [212537]|69.96||||69.96|34.98|53.17|0.88
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AARP [1000]|AARP [100000]|69.96||||69.96||53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AETNA [1015]|AETNA [101529]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AMBETTER [2930]|AMBETTER [293000]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69.96||||69.96|5.11|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|50.37|53.17|5.11
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]|69.96||||69.96|34.98|53.17|5.11
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]|69.96||||69.96|34.98|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69.96||||69.96|53.17|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69.96||||69.96|48.27|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA [1260]|CIGNA PPO [126025]|69.96||||69.96|27.98|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69.96||||69.96||53.17|5.11
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]|69.96||||69.96|48.27|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69.96||||69.96|5.11|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69.96||||69.96|48.27|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96|48.27|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|Self-pay|Self-pay|69.96||||69.96|13.99|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|TML [1980]|TML [198000]|69.96||||69.96|48.27|53.17|5.11
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]|69.96||||69.96|27.23|53.17|5.11
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]|69.96||||69.96||53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNICARE [2040]|UNICARE [204000]|69.96||||69.96||53.17|5.11
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]|69.96||||69.96||53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WEB TPA [2115]|WEB TPA [211500]|69.96||||69.96|48.27|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
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]|69.96||||69.96|0|53.17|5.11
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WORKER'S COMP [2125]|TML WC [212537]|69.96||||69.96||53.17|5.11
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|2.78||||2.78||2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.78||||2.78|1.39|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.78||||2.78|1.08|2.11|0.56
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]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.78||||2.78|2|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.78||||2.78|1.39|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.78||||2.78|1.39|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.78||||2.78|2.11|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.78||||2.78|1.92|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|2.78||||2.78|1.11|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.78||||2.78||2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.78||||2.78|1.92|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.78||||2.78|1.39|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.78||||2.78|1.92|2.11|0.56
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]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.78||||2.78|0|2.11|0.56
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]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.78||||2.78|1.92|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|2.78||||2.78|0.56|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|TML [1980]|TML [198000]|2.78||||2.78|1.92|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.78||||2.78|1.08|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.78||||2.78||2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNICARE [2040]|UNICARE [204000]|2.78||||2.78||2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.78||||2.78||2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|2.78||||2.78|1.92|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.78||||2.78|0|2.11|0.56
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]|2.78||||2.78|0|2.11|0.56
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|2.78||||2.78||2.11|0.56
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]|5.02||||5.02||3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|0|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|0|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.02||||5.02|2.51|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|3.61|3.82|1
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]|5.02||||5.02|2.51|3.82|1
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]|5.02||||5.02|2.51|3.82|1
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 TRADITIONAL OF TEXAS [115503]|5.02||||5.02|3.82|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|0|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.02||||5.02|3.46|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.02||||5.02|2.01|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.02||||5.02||3.82|1
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]|5.02||||5.02|3.46|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.02||||5.02|2.51|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.02||||5.02|3.46|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|3.46|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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|5.02||||5.02|1|3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|5.02||||5.02|3.46|3.82|1
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]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02||3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|5.02||||5.02||3.82|1
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]|5.02||||5.02||3.82|1
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.02||||5.02|3.46|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|0|3.82|1
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]|TML WC [212537]|5.02||||5.02||3.82|1
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AARP [1000]|AARP [100000]|277.2||||277.2||1223.4|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]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AETNA [1015]|AETNA [101529]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|0.04|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|199.58|1223.4|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]|277.2||||277.2|138.6|1223.4|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]|277.2||||277.2|138.6|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|210.67|1223.4|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]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2||1223.4|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]|277.2||||277.2|191.27|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|0.04|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|1223.4|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]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2|191.27|1223.4|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]|277.2||||277.2|107.89|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|Self-pay|Self-pay|277.2||||277.2|55.44|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|TML [1980]|TML [198000]|277.2||||277.2|191.27|1223.4|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]|277.2||||277.2|107.89|1223.4|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]|277.2||||277.2||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNICARE [2040]|UNICARE [204000]|277.2||||277.2||1223.4|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]|277.2||||277.2||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|1223.4|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]|277.2||||277.2|0|1223.4|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]|277.2||||277.2|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AARP [1000]|AARP [100000]|1609.74||||1609.74||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AETNA [1015]|AETNA [101529]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMBETTER [2930]|AMBETTER [293000]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1609.74||||1609.74|0.04|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1609.74||||1609.74|1159.01|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1609.74||||1609.74|804.87|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1609.74||||1609.74|804.87|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1609.74||||1609.74|1223.4|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1609.74||||1609.74|643.9|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1609.74||||1609.74||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1609.74||||1609.74|0.04|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|Self-pay|Self-pay|1609.74||||1609.74|321.95|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|TML [1980]|TML [198000]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1609.74||||1609.74|626.51|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1609.74||||1609.74||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UNICARE [2040]|UNICARE [204000]|1609.74||||1609.74||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1609.74||||1609.74||1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WEB TPA [2115]|WEB TPA [211500]|1609.74||||1609.74|1110.72|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1609.74||||1609.74|0|1223.4|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1609.74||||1609.74||1223.4|0.04
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|1.92||||1.92||1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.92||||1.92|0.96|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.92||||1.92|1.38|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.92||||1.92|0.96|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.92||||1.92|0.96|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.92||||1.92|1.46|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.92||||1.92|0.77|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.92||||1.92||1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.92||||1.92|0.96|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|Self-pay|Self-pay|1.92||||1.92|0.38|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|TML [1980]|TML [198000]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.92||||1.92|0.75|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.92||||1.92||1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.92||||1.92||1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.92||||1.92||1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.92||||1.92|1.32|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.92||||1.92|0|1.46|0.38
126274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM GLUCONATE 27 MG MAGNESIUM (500 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.92||||1.92||1.46|0.38
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|12.82||||12.82||9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.82||||12.82|6.41|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.82||||12.82|9.23|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.82||||12.82|6.41|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.82||||12.82|6.41|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.82||||12.82|9.74|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.82||||12.82|5.13|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.82||||12.82||9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.82||||12.82|6.41|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|12.82||||12.82|2.56|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.82||||12.82|4.99|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.82||||12.82||9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.82||||12.82||9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.82||||12.82||9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.82||||12.82|8.85|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.82||||12.82|0|9.74|2.56
126304|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IRON ASPGL AND PS CMPLX 150 MG-VIT C 50 MG-SUCCINIC ACID 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.82||||12.82||9.74|2.56
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AARP [1000]|AARP [100000]|1.95||||1.95||1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AETNA [1015]|AETNA [101529]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AMBETTER [2930]|AMBETTER [293000]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.95||||1.95|0.98|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.95||||1.95|1.4|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.95||||1.95|0.98|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.95||||1.95|0.98|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.95||||1.95|1.48|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|CIGNA [1260]|CIGNA PPO [126025]|1.95||||1.95|0.78|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.95||||1.95||1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.95||||1.95|0.98|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|Self-pay|Self-pay|1.95||||1.95|0.39|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|TML [1980]|TML [198000]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.95||||1.95|0.76|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.95||||1.95||1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|UNICARE [2040]|UNICARE [204000]|1.95||||1.95||1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.95||||1.95||1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|WEB TPA [2115]|WEB TPA [211500]|1.95||||1.95|1.35|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.95||||1.95|0|1.48|0.39
126331|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT|1 packet|WORKER'S COMP [2125]|TML WC [212537]|1.95||||1.95||1.48|0.39
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|66||||66||50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|2.11|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66||50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|2.11|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|66||||66|13.2|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|66||||66||50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66|0|50.16|2.11
126404|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|66||||66||50.16|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|181.44||||181.44||137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.44||||181.44|2.11|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.44||||181.44|130.64|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.44||||181.44|90.72|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.44||||181.44|90.72|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.44||||181.44|137.89|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|181.44||||181.44|72.58|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.44||||181.44||137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.44||||181.44|2.11|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|181.44||||181.44|36.29|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.44||||181.44|70.62|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.44||||181.44||137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|181.44||||181.44||137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.44||||181.44||137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|181.44||||181.44|125.19|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.44||||181.44|0|137.89|2.11
126405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|181.44||||181.44||137.89|2.11
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AARP [1000]|AARP [100000]|37224.4||||37224.4||28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AETNA [1015]|AETNA [101529]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AMBETTER [2930]|AMBETTER [293000]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37224.4||||37224.4|18612.2|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37224.4||||37224.4|26801.57|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37224.4||||37224.4|18612.2|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37224.4||||37224.4|18612.2|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37224.4||||37224.4|28290.54|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|CIGNA [1260]|CIGNA PPO [126025]|37224.4||||37224.4|14889.76|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37224.4||||37224.4||28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37224.4||||37224.4|18612.2|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|Self-pay|Self-pay|37224.4||||37224.4|7444.88|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|TML [1980]|TML [198000]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37224.4||||37224.4|14487.74|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37224.4||||37224.4||28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|UNICARE [2040]|UNICARE [204000]|37224.4||||37224.4||28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37224.4||||37224.4||28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|WEB TPA [2115]|WEB TPA [211500]|37224.4||||37224.4|25684.84|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37224.4||||37224.4|0|28290.54|7444.88
126579|ERX|0250 - PHARMACY-GENERAL|DANTROLENE 250 MG INTRAVENOUS SUSPENSION|250 mg|WORKER'S COMP [2125]|TML WC [212537]|37224.4||||37224.4||28290.54|7444.88
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|241.37||||241.37||183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|241.37||||241.37|120.69|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|241.37||||241.37|173.79|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|241.37||||241.37|120.69|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|241.37||||241.37|120.69|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|241.37||||241.37|183.44|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|241.37||||241.37|96.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|241.37||||241.37||183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|241.37||||241.37|120.69|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|Self-pay|Self-pay|241.37||||241.37|48.27|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|241.37||||241.37|93.94|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|241.37||||241.37||183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|241.37||||241.37||183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|241.37||||241.37||183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|241.37||||241.37|166.55|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|241.37||||241.37|0|183.44|48.27
126632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|241.37||||241.37||183.44|48.27
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|1167.54||||1167.54||887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1167.54||||1167.54|164.92|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1167.54||||1167.54|840.63|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1167.54||||1167.54|583.77|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1167.54||||1167.54|583.77|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1167.54||||1167.54|887.33|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1167.54||||1167.54|467.02|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1167.54||||1167.54||887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1167.54||||1167.54|164.92|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|Self-pay|Self-pay|1167.54||||1167.54|233.51|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|TML [1980]|TML [198000]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1167.54||||1167.54|454.41|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1167.54||||1167.54||887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|1167.54||||1167.54||887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1167.54||||1167.54||887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|1167.54||||1167.54|805.6|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1167.54||||1167.54|0|887.33|164.92
126699|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1167.54||||1167.54||887.33|164.92
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]|806.66||||806.66||613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AMBETTER [2930]|AMBETTER [293000]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|806.66||||806.66|182.99|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|580.8|613.06|161.33
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]|806.66||||806.66|403.33|613.06|161.33
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]|806.66||||806.66|403.33|613.06|161.33
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 TRADITIONAL OF TEXAS [115503]|806.66||||806.66|613.06|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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 - GREAT WEST [126009]|806.66||||806.66|556.6|613.06|161.33
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 PPO [126025]|806.66||||806.66|322.66|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|806.66||||806.66||613.06|161.33
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]|806.66||||806.66|556.6|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|806.66||||806.66|182.99|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|806.66||||806.66|556.6|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66|556.6|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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|806.66||||806.66|161.33|613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|TML [1980]|TML [198000]|806.66||||806.66|556.6|613.06|161.33
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]|806.66||||806.66|313.95|613.06|161.33
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]|806.66||||806.66||613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UNICARE [2040]|UNICARE [204000]|806.66||||806.66||613.06|161.33
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]|806.66||||806.66||613.06|161.33
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|WEB TPA [2115]|WEB TPA [211500]|806.66||||806.66|556.6|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|806.66||||806.66|0|613.06|161.33
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]|TML WC [212537]|806.66||||806.66||613.06|161.33
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]|324.74||||324.74||246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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|AMBETTER [2930]|AMBETTER [293000]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|324.74||||324.74|36.67|246.8|36.67
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 MEDICAID [1165]|BCBS MEDICAID [116504]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|233.81|246.8|36.67
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]|324.74||||324.74|162.37|246.8|36.67
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]|324.74||||324.74|162.37|246.8|36.67
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 TRADITIONAL OF TEXAS [115503]|324.74||||324.74|246.8|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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 - GREAT WEST [126009]|324.74||||324.74|224.07|246.8|36.67
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 PPO [126025]|324.74||||324.74|129.9|246.8|36.67
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|324.74||||324.74||246.8|36.67
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]|324.74||||324.74|224.07|246.8|36.67
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|324.74||||324.74|36.67|246.8|36.67
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|324.74||||324.74|224.07|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74|224.07|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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|324.74||||324.74|64.95|246.8|36.67
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|TML [1980]|TML [198000]|324.74||||324.74|224.07|246.8|36.67
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]|324.74||||324.74|126.39|246.8|36.67
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]|324.74||||324.74||246.8|36.67
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|UNICARE [2040]|UNICARE [204000]|324.74||||324.74||246.8|36.67
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]|324.74||||324.74||246.8|36.67
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|WEB TPA [2115]|WEB TPA [211500]|324.74||||324.74|224.07|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|324.74||||324.74|0|246.8|36.67
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]|TML WC [212537]|324.74||||324.74||246.8|36.67
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AARP [1000]|AARP [100000]|65.61||||65.61||49.86|13.12
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]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AETNA [1015]|AETNA [101529]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AMBETTER [2930]|AMBETTER [293000]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.61||||65.61|25.54|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|65.61||||65.61|32.81|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|65.61||||65.61|25.54|49.86|13.12
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]|65.61||||65.61|0|49.86|13.12
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]|65.61||||65.61|47.24|49.86|13.12
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]|65.61||||65.61|32.81|49.86|13.12
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]|65.61||||65.61|32.81|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|65.61||||65.61|49.86|49.86|13.12
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]|65.61||||65.61|25.54|49.86|13.12
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]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|65.61||||65.61|45.27|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|CIGNA [1260]|CIGNA PPO [126025]|65.61||||65.61|26.24|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|65.61||||65.61||49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|65.61||||65.61|45.27|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|65.61||||65.61|32.81|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.61||||65.61|45.27|49.86|13.12
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]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.61||||65.61|25.54|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.61||||65.61|0|49.86|13.12
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]|65.61||||65.61|25.54|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|65.61||||65.61|45.27|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.61||||65.61|25.54|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|Self-pay|Self-pay|65.61||||65.61|13.12|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|TML [1980]|TML [198000]|65.61||||65.61|45.27|49.86|13.12
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]|65.61||||65.61|25.54|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.61||||65.61||49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UNICARE [2040]|UNICARE [204000]|65.61||||65.61||49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.61||||65.61||49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|WEB TPA [2115]|WEB TPA [211500]|65.61||||65.61|45.27|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.61||||65.61|0|49.86|13.12
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]|65.61||||65.61|0|49.86|13.12
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|WORKER'S COMP [2125]|TML WC [212537]|65.61||||65.61||49.86|13.12
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|193.25||||193.25||146.87|38.65
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]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.25||||193.25|75.21|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.25||||193.25|96.63|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.25||||193.25|75.21|146.87|38.65
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]|193.25||||193.25|0|146.87|38.65
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]|193.25||||193.25|139.14|146.87|38.65
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]|193.25||||193.25|96.63|146.87|38.65
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]|193.25||||193.25|96.63|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.25||||193.25|146.87|146.87|38.65
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]|193.25||||193.25|75.21|146.87|38.65
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]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.25||||193.25|133.34|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|193.25||||193.25|77.3|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.25||||193.25||146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|193.25||||193.25|133.34|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.25||||193.25|96.63|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.25||||193.25|133.34|146.87|38.65
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]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.25||||193.25|75.21|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.25||||193.25|0|146.87|38.65
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]|193.25||||193.25|75.21|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|193.25||||193.25|133.34|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.25||||193.25|75.21|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|193.25||||193.25|38.65|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|193.25||||193.25|133.34|146.87|38.65
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]|193.25||||193.25|75.21|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.25||||193.25||146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|193.25||||193.25||146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.25||||193.25||146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|193.25||||193.25|133.34|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.25||||193.25|0|146.87|38.65
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]|193.25||||193.25|0|146.87|38.65
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|193.25||||193.25||146.87|38.65
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|217.8||||217.8||165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|217.8||||217.8|9.93|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.8||||217.8|156.82|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.8||||217.8|108.9|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.8||||217.8|108.9|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|217.8||||217.8|165.53|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|217.8||||217.8|87.12|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|217.8||||217.8||165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|217.8||||217.8|9.93|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|217.8||||217.8|43.56|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.8||||217.8|84.77|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.8||||217.8||165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|217.8||||217.8||165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.8||||217.8||165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|217.8||||217.8|150.28|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.8||||217.8|0|165.53|9.93
127749|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOCARBAMOL 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|217.8||||217.8||165.53|9.93
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AARP [1000]|AARP [100000]|4736.3||||4736.3||3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AETNA [1015]|AETNA [101529]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMBETTER [2930]|AMBETTER [293000]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4736.3||||4736.3|119.96|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4736.3||||4736.3|1843.37|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|3410.14|3599.59|119.96
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]|4736.3||||4736.3|2368.15|3599.59|119.96
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]|4736.3||||4736.3|2368.15|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4736.3||||4736.3|3599.59|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4736.3||||4736.3|3268.05|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA [1260]|CIGNA PPO [126025]|4736.3||||4736.3|1894.52|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4736.3||||4736.3||3599.59|119.96
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]|4736.3||||4736.3|3268.05|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4736.3||||4736.3|119.96|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4736.3||||4736.3|3268.05|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|4736.3||||4736.3|3268.05|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|Self-pay|Self-pay|4736.3||||4736.3|947.26|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|TML [1980]|TML [198000]|4736.3||||4736.3|3268.05|3599.59|119.96
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]|4736.3||||4736.3|1843.37|3599.59|119.96
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]|4736.3||||4736.3||3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNICARE [2040]|UNICARE [204000]|4736.3||||4736.3||3599.59|119.96
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]|4736.3||||4736.3||3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WEB TPA [2115]|WEB TPA [211500]|4736.3||||4736.3|3268.05|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
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]|4736.3||||4736.3|0|3599.59|119.96
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WORKER'S COMP [2125]|TML WC [212537]|4736.3||||4736.3||3599.59|119.96
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|457.19||||457.19||347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|457.19||||457.19|32.98|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|457.19||||457.19|329.18|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|457.19||||457.19|228.6|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|457.19||||457.19|228.6|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|457.19||||457.19|347.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|457.19||||457.19|182.88|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|457.19||||457.19||347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|457.19||||457.19|32.98|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|457.19||||457.19|91.44|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|TML [1980]|TML [198000]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|457.19||||457.19|177.94|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|457.19||||457.19||347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|457.19||||457.19||347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|457.19||||457.19||347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|457.19||||457.19|315.46|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|457.19||||457.19|0|347.46|32.98
128427|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|457.19||||457.19||347.46|32.98
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AARP [1000]|AARP [100000]|84.48||||84.48||64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AETNA [1015]|AETNA [101529]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMBETTER [2930]|AMBETTER [293000]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.48||||84.48|32.88|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84.48||||84.48|42.24|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84.48||||84.48|32.88|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
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]|84.48||||84.48|60.83|64.2|16.9
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]|84.48||||84.48|42.24|64.2|16.9
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]|84.48||||84.48|42.24|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84.48||||84.48|64.2|64.2|16.9
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]|84.48||||84.48|32.88|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84.48||||84.48|58.29|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|84.48||||84.48|33.79|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84.48||||84.48||64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|84.48||||84.48|58.29|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84.48||||84.48|42.24|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84.48||||84.48|58.29|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.48||||84.48|0|64.2|16.9
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]|84.48||||84.48|32.88|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.48||||84.48|0|64.2|16.9
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]|84.48||||84.48|32.88|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|84.48||||84.48|58.29|64.2|16.9
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]|84.48||||84.48|32.88|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|Self-pay|Self-pay|84.48||||84.48|16.9|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|TML [1980]|TML [198000]|84.48||||84.48|58.29|64.2|16.9
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]|84.48||||84.48|32.88|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.48||||84.48||64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNICARE [2040]|UNICARE [204000]|84.48||||84.48||64.2|16.9
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]|84.48||||84.48||64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WEB TPA [2115]|WEB TPA [211500]|84.48||||84.48|58.29|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
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]|84.48||||84.48|0|64.2|16.9
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|84.48||||84.48||64.2|16.9
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|108.14||||108.14||82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108.14||||108.14|54.07|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.14||||108.14|77.86|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.14||||108.14|54.07|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.14||||108.14|54.07|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108.14||||108.14|82.19|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|108.14||||108.14|43.26|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108.14||||108.14||82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108.14||||108.14|54.07|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|108.14||||108.14|21.63|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.14||||108.14|42.09|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.14||||108.14||82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|108.14||||108.14||82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.14||||108.14||82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|108.14||||108.14|74.62|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.14||||108.14|0|82.19|21.63
128540|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVABRADINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|108.14||||108.14||82.19|21.63
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AARP [1000]|AARP [100000]|7711.71||||7711.71||5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AETNA [1015]|AETNA [101529]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AMBETTER [2930]|AMBETTER [293000]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7711.71||||7711.71|610.94|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7711.71||||7711.71|5552.43|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7711.71||||7711.71|3855.86|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7711.71||||7711.71|3855.86|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7711.71||||7711.71|5860.9|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|CIGNA [1260]|CIGNA PPO [126025]|7711.71||||7711.71|3855.86|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7711.71||||7711.71||5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7711.71||||7711.71|610.94|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|Self-pay|Self-pay|7711.71||||7711.71|1542.34|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|TML [1980]|TML [198000]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7711.71||||7711.71|3001.4|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7711.71||||7711.71||5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|UNICARE [2040]|UNICARE [204000]|7711.71||||7711.71||5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7711.71||||7711.71||5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|WEB TPA [2115]|WEB TPA [211500]|7711.71||||7711.71|5321.08|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7711.71||||7711.71|0|5860.9|610.94
128599|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS IMMUNE GLOBULIN (PF) 250 UNIT INTRAMUSCULAR SYRINGE|1 each|WORKER'S COMP [2125]|TML WC [212537]|7711.71||||7711.71||5860.9|610.94
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AARP [1000]|AARP [100000]|78.57||||78.57||59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AETNA [1015]|AETNA [101529]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AMBETTER [2930]|AMBETTER [293000]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|78.57||||78.57|39.29|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78.57||||78.57|56.57|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78.57||||78.57|39.29|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78.57||||78.57|39.29|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|78.57||||78.57|59.71|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|CIGNA [1260]|CIGNA PPO [126025]|78.57||||78.57|31.43|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|78.57||||78.57||59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|78.57||||78.57|39.29|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|Self-pay|Self-pay|78.57||||78.57|15.71|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|TML [1980]|TML [198000]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78.57||||78.57|30.58|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.57||||78.57||59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|UNICARE [2040]|UNICARE [204000]|78.57||||78.57||59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.57||||78.57||59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|WEB TPA [2115]|WEB TPA [211500]|78.57||||78.57|54.21|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78.57||||78.57|0|59.71|15.71
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|6 mL|WORKER'S COMP [2125]|TML WC [212537]|78.57||||78.57||59.71|15.71
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AARP [1000]|AARP [100000]|277.2||||277.2||210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AETNA [1015]|AETNA [101529]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|0.86|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|199.58|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|138.6|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|138.6|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|210.67|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2||210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|0.86|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|Self-pay|Self-pay|277.2||||277.2|55.44|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|TML [1980]|TML [198000]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|107.89|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2||210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UNICARE [2040]|UNICARE [204000]|277.2||||277.2||210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2||210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.2||||277.2|0|210.67|0.86
128845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 800 MG/500 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|500 mL|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2||210.67|0.86
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|86.99||||86.99||66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|86.99||||86.99|43.5|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|62.63|66.11|17.4
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]|86.99||||86.99|43.5|66.11|17.4
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]|86.99||||86.99|43.5|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|86.99||||86.99|66.11|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|86.99||||86.99|60.02|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|86.99||||86.99|34.8|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|86.99||||86.99||66.11|17.4
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]|86.99||||86.99|60.02|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|86.99||||86.99|43.5|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|86.99||||86.99|60.02|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99|60.02|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|86.99||||86.99|17.4|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|86.99||||86.99|60.02|66.11|17.4
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]|86.99||||86.99|33.86|66.11|17.4
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]|86.99||||86.99||66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|86.99||||86.99||66.11|17.4
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]|86.99||||86.99||66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|86.99||||86.99|60.02|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
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]|86.99||||86.99|0|66.11|17.4
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|86.99||||86.99||66.11|17.4
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AARP [1000]|AARP [100000]|270.6||||270.6||205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA [1015]|AETNA [101529]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|270.6||||270.6|135.3|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270.6||||270.6|194.83|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270.6||||270.6|135.3|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270.6||||270.6|135.3|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|270.6||||270.6|205.66|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA [1260]|CIGNA PPO [126025]|270.6||||270.6|108.24|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|270.6||||270.6||205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|270.6||||270.6|135.3|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|Self-pay|Self-pay|270.6||||270.6|54.12|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|TML [1980]|TML [198000]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270.6||||270.6|105.32|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270.6||||270.6||205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|UNICARE [2040]|UNICARE [204000]|270.6||||270.6||205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270.6||||270.6||205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|270.6||||270.6|186.71|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270.6||||270.6|0|205.66|54.12
129081|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN 0.9 % NACL IV|250 mL|WORKER'S COMP [2125]|TML WC [212537]|270.6||||270.6||205.66|54.12
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.99||||10.99||8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.99||||10.99|5.5|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.99||||10.99|4.28|8.35|2.2
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]|10.99||||10.99|0|8.35|2.2
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]|10.99||||10.99|7.91|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.99||||10.99|5.5|8.35|2.2
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]|10.99||||10.99|5.5|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.99||||10.99|8.35|8.35|2.2
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]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.99||||10.99|7.58|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.99||||10.99|4.4|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.99||||10.99||8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.99||||10.99|7.58|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.99||||10.99|5.5|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.99||||10.99|7.58|8.35|2.2
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]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.99||||10.99|0|8.35|2.2
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]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.99||||10.99|7.58|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|Self-pay|Self-pay|10.99||||10.99|2.2|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.99||||10.99|7.58|8.35|2.2
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]|10.99||||10.99|4.28|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.99||||10.99||8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.99||||10.99||8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.99||||10.99||8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.99||||10.99|7.58|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.99||||10.99|0|8.35|2.2
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]|10.99||||10.99|0|8.35|2.2
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.99||||10.99||8.35|2.2
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AARP [1000]|AARP [100000]|4.24||||4.24||3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.24||||4.24|2.12|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.24||||4.24|1.65|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|3.05|3.22|0.85
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]|4.24||||4.24|2.12|3.22|0.85
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]|4.24||||4.24|2.12|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.24||||4.24|3.22|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.24||||4.24|2.93|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.24||||4.24|1.7|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.24||||4.24||3.22|0.85
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]|4.24||||4.24|2.93|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.24||||4.24|2.12|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.24||||4.24|2.93|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.24||||4.24|2.93|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|Self-pay|Self-pay|4.24||||4.24|0.85|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|TML [1980]|TML [198000]|4.24||||4.24|2.93|3.22|0.85
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]|4.24||||4.24|1.65|3.22|0.85
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]|4.24||||4.24||3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.24||||4.24||3.22|0.85
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]|4.24||||4.24||3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.24||||4.24|2.93|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
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]|4.24||||4.24|0|3.22|0.85
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.24||||4.24||3.22|0.85
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AARP [1000]|AARP [100000]|26.8||||26.8||20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AETNA [1015]|AETNA [101529]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMBETTER [2930]|AMBETTER [293000]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.8||||26.8|13.4|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.8||||26.8|10.43|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|19.3|20.37|5.36
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]|26.8||||26.8|13.4|20.37|5.36
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]|26.8||||26.8|13.4|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.8||||26.8|20.37|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.8||||26.8|18.49|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA [1260]|CIGNA PPO [126025]|26.8||||26.8|10.72|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.8||||26.8||20.37|5.36
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]|26.8||||26.8|18.49|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.8||||26.8|13.4|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.8||||26.8|18.49|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|26.8||||26.8|18.49|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|Self-pay|Self-pay|26.8||||26.8|5.36|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|TML [1980]|TML [198000]|26.8||||26.8|18.49|20.37|5.36
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]|26.8||||26.8|10.43|20.37|5.36
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]|26.8||||26.8||20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNICARE [2040]|UNICARE [204000]|26.8||||26.8||20.37|5.36
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]|26.8||||26.8||20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WEB TPA [2115]|WEB TPA [211500]|26.8||||26.8|18.49|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
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]|26.8||||26.8|0|20.37|5.36
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WORKER'S COMP [2125]|TML WC [212537]|26.8||||26.8||20.37|5.36
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|15.18||||15.18||11.54|0.78
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]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.18||||15.18|5.91|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.18||||15.18|0.78|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.18||||15.18|5.91|11.54|0.78
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]|15.18||||15.18|0|11.54|0.78
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]|15.18||||15.18|10.93|11.54|0.78
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]|15.18||||15.18|7.59|11.54|0.78
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]|15.18||||15.18|7.59|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.18||||15.18|11.54|11.54|0.78
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]|15.18||||15.18|5.91|11.54|0.78
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]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.18||||15.18|10.47|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|15.18||||15.18|6.07|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.18||||15.18||11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|15.18||||15.18|10.47|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.18||||15.18|0.78|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.18||||15.18|10.47|11.54|0.78
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]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.18||||15.18|5.91|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.18||||15.18|0|11.54|0.78
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]|15.18||||15.18|5.91|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|15.18||||15.18|10.47|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.18||||15.18|5.91|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|15.18||||15.18|3.04|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TML [1980]|TML [198000]|15.18||||15.18|10.47|11.54|0.78
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]|15.18||||15.18|5.91|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.18||||15.18||11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|15.18||||15.18||11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.18||||15.18||11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|15.18||||15.18|10.47|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.18||||15.18|0|11.54|0.78
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]|15.18||||15.18|0|11.54|0.78
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|15.18||||15.18||11.54|0.78
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|2826.78||||2826.78||2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2826.78||||2826.78|275.89|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2826.78||||2826.78|2035.28|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2826.78||||2826.78|1413.39|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2826.78||||2826.78|1413.39|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2826.78||||2826.78|2148.35|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|2826.78||||2826.78|1130.71|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2826.78||||2826.78||2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2826.78||||2826.78|275.89|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|2826.78||||2826.78|565.36|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|TML [1980]|TML [198000]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2826.78||||2826.78|1100.18|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2826.78||||2826.78||2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|2826.78||||2826.78||2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2826.78||||2826.78||2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|2826.78||||2826.78|1950.48|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2826.78||||2826.78|0|2148.35|275.89
12935|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|2826.78||||2826.78||2148.35|275.89
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||114|30
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|0|114|30
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|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AMBETTER [2930]|AMBETTER [293000]|150||||150|0|114|30
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|58.38|114|30
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|0|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|150||||150|75|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|150||||150|58.38|114|30
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|0|114|30
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|108|114|30
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|114|30
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|75|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|150||||150|114|114|30
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|58.38|114|30
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|0|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|150||||150|103.5|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA PPO [126025]|150||||150|60|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|150||||150||114|30
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|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|150||||150|75|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|150||||150|103.5|114|30
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|0|114|30
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|114|30
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|58.38|114|30
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|0|114|30
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|114|30
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|58.38|114|30
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|114|30
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|58.38|114|30
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|30|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|TML [1980]|TML [198000]|150||||150|103.5|114|30
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|58.38|114|30
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||114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UNICARE [2040]|UNICARE [204000]|150||||150||114|30
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||114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|WEB TPA [2115]|WEB TPA [211500]|150||||150|103.5|114|30
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|0|114|30
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|0|114|30
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|WORKER'S COMP [2125]|TML WC [212537]|150||||150||114|30
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|153.7|233.62|61.48
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|0|233.62|61.48
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|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AMBETTER [2930]|AMBETTER [293000]|307.4||||307.4|0|233.62|61.48
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|119.64|233.62|61.48
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|0|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|307.4||||307.4|153.7|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|307.4||||307.4|119.64|233.62|61.48
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|0|233.62|61.48
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|221.33|233.62|61.48
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|233.62|61.48
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|153.7|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|307.4||||307.4|233.62|233.62|61.48
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|119.64|233.62|61.48
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|0|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|307.4||||307.4|212.11|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|CIGNA [1260]|CIGNA PPO [126025]|307.4||||307.4|122.96|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|307.4||||307.4|153.7|233.62|61.48
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|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|307.4||||307.4|153.7|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|307.4||||307.4|212.11|233.62|61.48
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|0|233.62|61.48
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|233.62|61.48
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|119.64|233.62|61.48
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|0|233.62|61.48
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|233.62|61.48
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|119.64|233.62|61.48
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|233.62|61.48
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|119.64|233.62|61.48
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|61.48|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|TML [1980]|TML [198000]|307.4||||307.4|212.11|233.62|61.48
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|119.64|233.62|61.48
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|153.7|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UNICARE [2040]|UNICARE [204000]|307.4||||307.4|153.7|233.62|61.48
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|153.7|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|WEB TPA [2115]|WEB TPA [211500]|307.4||||307.4|212.11|233.62|61.48
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|0|233.62|61.48
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|0|233.62|61.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|WORKER'S COMP [2125]|TML WC [212537]|307.4||||307.4|153.7|233.62|61.48
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]|193.38||||193.38|96.69|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.38||||193.38|0.82|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|139.23|146.97|0.82
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]|193.38||||193.38|96.69|146.97|0.82
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]|193.38||||193.38|96.69|146.97|0.82
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 TRADITIONAL OF TEXAS [115503]|193.38||||193.38|146.97|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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 - GREAT WEST [126009]|193.38||||193.38|133.43|146.97|0.82
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 PPO [126025]|193.38||||193.38|77.35|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.38||||193.38|96.69|146.97|0.82
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]|193.38||||193.38|133.43|146.97|0.82
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.38||||193.38|0.82|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.38||||193.38|133.43|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|133.43|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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|193.38||||193.38|38.68|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|TML [1980]|TML [198000]|193.38||||193.38|133.43|146.97|0.82
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]|193.38||||193.38|75.26|146.97|0.82
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]|193.38||||193.38|96.69|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNICARE [2040]|UNICARE [204000]|193.38||||193.38|96.69|146.97|0.82
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]|193.38||||193.38|96.69|146.97|0.82
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|193.38||||193.38|133.43|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|193.38||||193.38|0|146.97|0.82
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]|TML WC [212537]|193.38||||193.38|96.69|146.97|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|96.36||||96.36|0.82|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96.36||||96.36|69.38|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|96.36||||96.36|73.23|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|96.36||||96.36|38.54|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|96.36||||96.36|0.82|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|96.36||||96.36|19.27|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96.36||||96.36|37.5|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96.36||||96.36|48.18|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|96.36||||96.36|66.49|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96.36||||96.36|0|73.23|0.82
129652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|96.36||||96.36|48.18|73.23|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72.6||||72.6|0.82|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72.6||||72.6|52.27|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|72.6||||72.6|55.18|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|72.6||||72.6|29.04|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72.6||||72.6|0.82|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|72.6||||72.6|14.52|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|TML [1980]|TML [198000]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72.6||||72.6|28.26|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72.6||||72.6|36.3|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|72.6||||72.6|50.09|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72.6||||72.6|0|55.18|0.82
129653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|72.6||||72.6|36.3|55.18|0.82
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|84717.47||||84717.47||64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84717.47||||84717.47|4003.34|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84717.47||||84717.47|60996.58|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84717.47||||84717.47|42358.74|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84717.47||||84717.47|42358.74|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84717.47||||84717.47|64385.28|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|84717.47||||84717.47|42358.74|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84717.47||||84717.47||64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84717.47||||84717.47|4003.34|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|Self-pay|Self-pay|84717.47||||84717.47|16943.49|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TML [1980]|TML [198000]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84717.47||||84717.47|32972.04|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84717.47||||84717.47||64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNICARE [2040]|UNICARE [204000]|84717.47||||84717.47||64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84717.47||||84717.47||64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|84717.47||||84717.47|58455.05|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84717.47||||84717.47|0|64385.28|4003.34
129657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|84717.47||||84717.47||64385.28|4003.34
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||205.2|54
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|0|205.2|54
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|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AMBETTER [2930]|AMBETTER [293000]|270||||270|0|205.2|54
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|105.08|205.2|54
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|0|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|270||||270|135|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|270||||270|105.08|205.2|54
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|0|205.2|54
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|194.4|205.2|54
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|205.2|54
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|135|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|270||||270|205.2|205.2|54
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|105.08|205.2|54
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|0|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|270||||270|186.3|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|CIGNA [1260]|CIGNA PPO [126025]|270||||270|108|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|270||||270||205.2|54
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|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|270||||270|135|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|270||||270|186.3|205.2|54
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|0|205.2|54
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|205.2|54
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|105.08|205.2|54
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|0|205.2|54
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|205.2|54
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|105.08|205.2|54
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|205.2|54
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|105.08|205.2|54
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|54|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|TML [1980]|TML [198000]|270||||270|186.3|205.2|54
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|105.08|205.2|54
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||205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UNICARE [2040]|UNICARE [204000]|270||||270||205.2|54
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||205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|WEB TPA [2115]|WEB TPA [211500]|270||||270|186.3|205.2|54
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|0|205.2|54
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|0|205.2|54
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|WORKER'S COMP [2125]|TML WC [212537]|270||||270||205.2|54
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|381.34||||381.34||289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|381.34||||381.34|46.66|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.34||||381.34|274.56|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.34||||381.34|190.67|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.34||||381.34|190.67|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|381.34||||381.34|289.82|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|381.34||||381.34|152.54|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|381.34||||381.34||289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|381.34||||381.34|46.66|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|381.34||||381.34|76.27|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.34||||381.34|148.42|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.34||||381.34||289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|381.34||||381.34||289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.34||||381.34||289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|381.34||||381.34|263.12|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.34||||381.34|0|289.82|46.66
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|381.34||||381.34||289.82|46.66
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]|376.6||||376.6||286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|376.6||||376.6|18.4|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|271.15|286.22|18.4
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]|376.6||||376.6|188.3|286.22|18.4
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]|376.6||||376.6|188.3|286.22|18.4
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 TRADITIONAL OF TEXAS [115503]|376.6||||376.6|286.22|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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 - GREAT WEST [126009]|376.6||||376.6|259.85|286.22|18.4
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 PPO [126025]|376.6||||376.6|150.64|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|376.6||||376.6||286.22|18.4
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]|376.6||||376.6|259.85|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|376.6||||376.6|18.4|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|376.6||||376.6|259.85|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6|259.85|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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|376.6||||376.6|75.32|286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|TML [1980]|TML [198000]|376.6||||376.6|259.85|286.22|18.4
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]|376.6||||376.6|146.57|286.22|18.4
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]|376.6||||376.6||286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNICARE [2040]|UNICARE [204000]|376.6||||376.6||286.22|18.4
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]|376.6||||376.6||286.22|18.4
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|376.6||||376.6|259.85|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|376.6||||376.6|0|286.22|18.4
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]|TML WC [212537]|376.6||||376.6||286.22|18.4
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]|203.55||||203.55||154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|203.55||||203.55|18.4|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|146.56|154.7|18.4
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]|203.55||||203.55|101.78|154.7|18.4
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]|203.55||||203.55|101.78|154.7|18.4
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 TRADITIONAL OF TEXAS [115503]|203.55||||203.55|154.7|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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 - GREAT WEST [126009]|203.55||||203.55|140.45|154.7|18.4
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 PPO [126025]|203.55||||203.55|81.42|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|203.55||||203.55||154.7|18.4
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]|203.55||||203.55|140.45|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|203.55||||203.55|18.4|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|203.55||||203.55|140.45|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55|140.45|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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|203.55||||203.55|40.71|154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|TML [1980]|TML [198000]|203.55||||203.55|140.45|154.7|18.4
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]|203.55||||203.55|79.22|154.7|18.4
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]|203.55||||203.55||154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNICARE [2040]|UNICARE [204000]|203.55||||203.55||154.7|18.4
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]|203.55||||203.55||154.7|18.4
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|203.55||||203.55|140.45|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|203.55||||203.55|0|154.7|18.4
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]|TML WC [212537]|203.55||||203.55||154.7|18.4
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AARP [1000]|AARP [100000]|293.7||||293.7||223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA [1015]|AETNA [101529]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|293.7||||293.7|146.85|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|293.7||||293.7|211.46|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|293.7||||293.7|146.85|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|293.7||||293.7|146.85|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|293.7||||293.7|223.21|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA [1260]|CIGNA PPO [126025]|293.7||||293.7|117.48|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|293.7||||293.7||223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|293.7||||293.7|146.85|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|Self-pay|Self-pay|293.7||||293.7|58.74|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|TML [1980]|TML [198000]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|293.7||||293.7|114.31|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|293.7||||293.7||223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|UNICARE [2040]|UNICARE [204000]|293.7||||293.7||223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|293.7||||293.7||223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|293.7||||293.7|202.65|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|293.7||||293.7|0|223.21|58.74
129887|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV|250 mL|WORKER'S COMP [2125]|TML WC [212537]|293.7||||293.7||223.21|58.74
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|128.24||||128.24||97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.24||||128.24|49.91|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.24||||128.24|64.12|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|92.33|97.46|25.65
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]|128.24||||128.24|64.12|97.46|25.65
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]|128.24||||128.24|64.12|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.24||||128.24|97.46|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.24||||128.24|88.49|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|128.24||||128.24|51.3|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.24||||128.24||97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|128.24||||128.24|88.49|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.24||||128.24|64.12|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|Self-pay|Self-pay|128.24||||128.24|25.65|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|TML [1980]|TML [198000]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.24||||128.24||97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|128.24||||128.24||97.46|25.65
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]|128.24||||128.24||97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|128.24||||128.24||97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|128.24||||128.24||97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.24||||128.24|49.91|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.24||||128.24|64.12|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|92.33|97.46|25.65
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]|128.24||||128.24|64.12|97.46|25.65
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]|128.24||||128.24|64.12|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.24||||128.24|97.46|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.24||||128.24|88.49|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|128.24||||128.24|51.3|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.24||||128.24||97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|128.24||||128.24|88.49|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.24||||128.24|64.12|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|Self-pay|Self-pay|128.24||||128.24|25.65|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|TML [1980]|TML [198000]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|49.91|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.24||||128.24||97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|128.24||||128.24||97.46|25.65
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]|128.24||||128.24||97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|128.24||||128.24|88.49|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
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]|128.24||||128.24|0|97.46|25.65
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|128.24||||128.24||97.46|25.65
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AARP [1000]|AARP [100000]|79.2||||79.2||60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|39.6|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.2||||79.2|57.02|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.2||||79.2|39.6|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.2||||79.2|39.6|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|60.19|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2||60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|39.6|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|Self-pay|Self-pay|79.2||||79.2|15.84|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|TML [1980]|TML [198000]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.2||||79.2|30.82|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2||60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|79.2||||79.2||60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.2||||79.2||60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.2||||79.2|0|60.19|15.84
129932|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2||60.19|15.84
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|56.66||||56.66||43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|56.66||||56.66|1.85|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.66||||56.66|40.8|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.66||||56.66|28.33|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.66||||56.66|28.33|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|56.66||||56.66|43.06|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|56.66||||56.66|22.66|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|56.66||||56.66||43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|56.66||||56.66|1.85|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|56.66||||56.66|11.33|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.66||||56.66|22.05|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.66||||56.66||43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|56.66||||56.66||43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.66||||56.66||43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|56.66||||56.66|39.1|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.66||||56.66|0|43.06|1.85
129950|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS XR 0.75 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|56.66||||56.66||43.06|1.85
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|90.85||||90.85||69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.85||||90.85|45.43|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.85||||90.85|65.41|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.85||||90.85|45.43|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.85||||90.85|45.43|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.85||||90.85|69.05|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.85||||90.85|36.34|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.85||||90.85||69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.85||||90.85|45.43|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|Self-pay|Self-pay|90.85||||90.85|18.17|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|TML [1980]|TML [198000]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.85||||90.85|35.36|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.85||||90.85||69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|90.85||||90.85||69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.85||||90.85||69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.85||||90.85|62.69|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.85||||90.85|0|69.05|18.17
130191|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.85||||90.85||69.05|18.17
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|781.75|1188.26|312.7
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|0|1188.26|312.7
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|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AMBETTER [2930]|AMBETTER [293000]|1563.5||||1563.5|0|1188.26|312.7
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|608.51|1188.26|312.7
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|0|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1563.5||||1563.5|781.75|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1563.5||||1563.5|608.51|1188.26|312.7
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|0|1188.26|312.7
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|1125.72|1188.26|312.7
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|1188.26|312.7
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|781.75|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1563.5||||1563.5|1188.26|1188.26|312.7
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|608.51|1188.26|312.7
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|0|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1563.5||||1563.5|1078.82|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|CIGNA [1260]|CIGNA PPO [126025]|1563.5||||1563.5|625.4|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1563.5||||1563.5|781.75|1188.26|312.7
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|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1563.5||||1563.5|781.75|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1563.5||||1563.5|1078.82|1188.26|312.7
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|0|1188.26|312.7
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|1188.26|312.7
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|608.51|1188.26|312.7
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|0|1188.26|312.7
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|1188.26|312.7
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|608.51|1188.26|312.7
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|1188.26|312.7
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|608.51|1188.26|312.7
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|312.7|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|TML [1980]|TML [198000]|1563.5||||1563.5|1078.82|1188.26|312.7
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|608.51|1188.26|312.7
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|781.75|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UNICARE [2040]|UNICARE [204000]|1563.5||||1563.5|781.75|1188.26|312.7
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|781.75|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|WEB TPA [2115]|WEB TPA [211500]|1563.5||||1563.5|1078.82|1188.26|312.7
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|0|1188.26|312.7
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|0|1188.26|312.7
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|WORKER'S COMP [2125]|TML WC [212537]|1563.5||||1563.5|781.75|1188.26|312.7
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28243.38||||28243.38|20335.23|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28243.38||||28243.38|21464.97|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|28243.38||||28243.38|5648.68|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28243.38||||28243.38|10992.32|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28243.38||||28243.38|14121.69|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|28243.38||||28243.38|19487.93|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28243.38||||28243.38|0|21464.97|5648.68
130445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|28243.38||||28243.38|14121.69|21464.97|5648.68
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AARP [1000]|AARP [100000]|93.99||||93.99||71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93.99||||93.99|47|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93.99||||93.99|36.58|71.43|18.8
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]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93.99||||93.99|67.67|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93.99||||93.99|47|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93.99||||93.99|47|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93.99||||93.99|71.43|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93.99||||93.99|64.85|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|93.99||||93.99|37.6|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93.99||||93.99||71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93.99||||93.99|64.85|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93.99||||93.99|47|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93.99||||93.99|64.85|71.43|18.8
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]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93.99||||93.99|0|71.43|18.8
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]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93.99||||93.99|64.85|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|Self-pay|Self-pay|93.99||||93.99|18.8|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|TML [1980]|TML [198000]|93.99||||93.99|64.85|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93.99||||93.99|36.58|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93.99||||93.99||71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|93.99||||93.99||71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93.99||||93.99||71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|93.99||||93.99|64.85|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93.99||||93.99|0|71.43|18.8
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]|93.99||||93.99|0|71.43|18.8
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|93.99||||93.99||71.43|18.8
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AARP [1000]|AARP [100000]|450||||450|225|342|90
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|0|342|90
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|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AMBETTER [2930]|AMBETTER [293000]|450||||450|0|342|90
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|175.14|342|90
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|0|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450||||450|225|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450||||450|175.14|342|90
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|0|342|90
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|324|342|90
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|342|90
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|225|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450||||450|342|342|90
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|175.14|342|90
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|0|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450||||450|310.5|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|CIGNA [1260]|CIGNA PPO [126025]|450||||450|180|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450||||450|225|342|90
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|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450||||450|225|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450||||450|310.5|342|90
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|0|342|90
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|342|90
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|175.14|342|90
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|0|342|90
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|342|90
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|175.14|342|90
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|342|90
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|175.14|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|Self-pay|Self-pay|450||||450|90|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|TML [1980]|TML [198000]|450||||450|310.5|342|90
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|175.14|342|90
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|225|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UNICARE [2040]|UNICARE [204000]|450||||450|225|342|90
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|225|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|WEB TPA [2115]|WEB TPA [211500]|450||||450|310.5|342|90
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|0|342|90
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|0|342|90
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|WORKER'S COMP [2125]|TML WC [212537]|450||||450|225|342|90
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]|8.19||||8.19||6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.19||||8.19|4.1|6.22|1.64
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 MEDICAID [1165]|BCBS MEDICAID [116504]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|5.9|6.22|1.64
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]|8.19||||8.19|4.1|6.22|1.64
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]|8.19||||8.19|4.1|6.22|1.64
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 TRADITIONAL OF TEXAS [115503]|8.19||||8.19|6.22|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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 - GREAT WEST [126009]|8.19||||8.19|5.65|6.22|1.64
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 PPO [126025]|8.19||||8.19|3.28|6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.19||||8.19||6.22|1.64
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]|8.19||||8.19|5.65|6.22|1.64
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.19||||8.19|4.1|6.22|1.64
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.19||||8.19|5.65|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19|5.65|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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|8.19||||8.19|1.64|6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|8.19||||8.19|5.65|6.22|1.64
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]|8.19||||8.19|3.19|6.22|1.64
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]|8.19||||8.19||6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|8.19||||8.19||6.22|1.64
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]|8.19||||8.19||6.22|1.64
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|8.19||||8.19|5.65|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|8.19||||8.19|0|6.22|1.64
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]|TML WC [212537]|8.19||||8.19||6.22|1.64
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|66.14||||66.14||50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.14||||66.14|5.01|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.14||||66.14|25.74|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|47.62|50.27|5.01
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]|66.14||||66.14|33.07|50.27|5.01
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]|66.14||||66.14|33.07|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.14||||66.14|50.27|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.14||||66.14|45.64|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|66.14||||66.14|26.46|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.14||||66.14||50.27|5.01
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]|66.14||||66.14|45.64|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.14||||66.14|5.01|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.14||||66.14|45.64|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66.14||||66.14|45.64|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|66.14||||66.14|13.23|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|66.14||||66.14|45.64|50.27|5.01
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]|66.14||||66.14|25.74|50.27|5.01
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]|66.14||||66.14||50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|66.14||||66.14||50.27|5.01
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]|66.14||||66.14||50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|66.14||||66.14|45.64|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
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]|66.14||||66.14|0|50.27|5.01
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|66.14||||66.14||50.27|5.01
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]|145.6||||145.6||110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.6||||145.6|72.8|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|104.83|110.66|29.12
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]|145.6||||145.6|72.8|110.66|29.12
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]|145.6||||145.6|72.8|110.66|29.12
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 TRADITIONAL OF TEXAS [115503]|145.6||||145.6|110.66|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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 - GREAT WEST [126009]|145.6||||145.6|100.46|110.66|29.12
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 PPO [126025]|145.6||||145.6|58.24|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.6||||145.6||110.66|29.12
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]|145.6||||145.6|100.46|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.6||||145.6|72.8|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.6||||145.6|100.46|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6|100.46|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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|145.6||||145.6|29.12|110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|145.6||||145.6|100.46|110.66|29.12
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]|145.6||||145.6|56.67|110.66|29.12
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]|145.6||||145.6||110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|145.6||||145.6||110.66|29.12
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]|145.6||||145.6||110.66|29.12
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|145.6||||145.6|100.46|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|145.6||||145.6|0|110.66|29.12
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]|TML WC [212537]|145.6||||145.6||110.66|29.12
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AARP [1000]|AARP [100000]|316.8||||316.8||240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AETNA [1015]|AETNA [101529]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AMBETTER [2930]|AMBETTER [293000]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|316.8||||316.8|158.4|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316.8||||316.8|228.1|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316.8||||316.8|158.4|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316.8||||316.8|158.4|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|316.8||||316.8|240.77|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA [1260]|CIGNA PPO [126025]|316.8||||316.8|126.72|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|316.8||||316.8||240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|316.8||||316.8|158.4|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|Self-pay|Self-pay|316.8||||316.8|63.36|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|TML [1980]|TML [198000]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316.8||||316.8|123.3|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316.8||||316.8||240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UNICARE [2040]|UNICARE [204000]|316.8||||316.8||240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316.8||||316.8||240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WEB TPA [2115]|WEB TPA [211500]|316.8||||316.8|218.59|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316.8||||316.8|0|240.77|63.36
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WORKER'S COMP [2125]|TML WC [212537]|316.8||||316.8||240.77|63.36
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|170.79||||170.79||129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|170.79||||170.79|85.4|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|170.79||||170.79|66.47|129.8|34.16
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]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.79||||170.79|122.97|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.79||||170.79|85.4|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.79||||170.79|85.4|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|170.79||||170.79|129.8|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|170.79||||170.79|117.85|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|170.79||||170.79|68.32|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|170.79||||170.79||129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|170.79||||170.79|117.85|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|170.79||||170.79|85.4|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|170.79||||170.79|117.85|129.8|34.16
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]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.79||||170.79|0|129.8|34.16
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]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|170.79||||170.79|117.85|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|Self-pay|Self-pay|170.79||||170.79|34.16|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|170.79||||170.79|117.85|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.79||||170.79|66.47|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.79||||170.79||129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|170.79||||170.79||129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.79||||170.79||129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|170.79||||170.79|117.85|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.79||||170.79|0|129.8|34.16
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]|170.79||||170.79|0|129.8|34.16
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|170.79||||170.79||129.8|34.16
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.39||||1.39||1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.39||||1.39|0.7|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.39||||1.39|1|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.39||||1.39|0.7|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.39||||1.39|0.7|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.39||||1.39|1.06|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.39||||1.39|0.56|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.39||||1.39||1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.39||||1.39|0.7|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|Self-pay|Self-pay|1.39||||1.39|0.28|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.39||||1.39|0.54|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.39||||1.39||1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.39||||1.39||1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.39||||1.39||1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.39||||1.39|0.96|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.39||||1.39|0|1.06|0.28
13135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN SODIUM 220 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.39||||1.39||1.06|0.28
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]|475.2||||475.2||361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|475.2||||475.2|237.6|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|342.14|361.15|95.04
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]|475.2||||475.2|237.6|361.15|95.04
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]|475.2||||475.2|237.6|361.15|95.04
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 TRADITIONAL OF TEXAS [115503]|475.2||||475.2|361.15|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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 - GREAT WEST [126009]|475.2||||475.2|327.89|361.15|95.04
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 PPO [126025]|475.2||||475.2|190.08|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|475.2||||475.2||361.15|95.04
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]|475.2||||475.2|327.89|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|475.2||||475.2|237.6|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|475.2||||475.2|327.89|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|327.89|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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|475.2||||475.2|95.04|361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|TML [1980]|TML [198000]|475.2||||475.2|327.89|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2||361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNICARE [2040]|UNICARE [204000]|475.2||||475.2||361.15|95.04
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]|475.2||||475.2||361.15|95.04
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|475.2||||475.2|327.89|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
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]|TML WC [212537]|475.2||||475.2||361.15|95.04
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]|16.31||||16.31||12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.31||||16.31|8.16|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|11.74|12.4|3.26
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]|16.31||||16.31|8.16|12.4|3.26
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]|16.31||||16.31|8.16|12.4|3.26
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 TRADITIONAL OF TEXAS [115503]|16.31||||16.31|12.4|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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 - GREAT WEST [126009]|16.31||||16.31|11.25|12.4|3.26
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 PPO [126025]|16.31||||16.31|6.52|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.31||||16.31||12.4|3.26
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]|16.31||||16.31|11.25|12.4|3.26
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.31||||16.31|8.16|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.31||||16.31|11.25|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31|11.25|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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|16.31||||16.31|3.26|12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TML [1980]|TML [198000]|16.31||||16.31|11.25|12.4|3.26
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]|16.31||||16.31|6.35|12.4|3.26
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]|16.31||||16.31||12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|16.31||||16.31||12.4|3.26
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]|16.31||||16.31||12.4|3.26
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|16.31||||16.31|11.25|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|16.31||||16.31|0|12.4|3.26
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]|TML WC [212537]|16.31||||16.31||12.4|3.26
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|384.25|584.06|153.7
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|0|584.06|153.7
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|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AMBETTER [2930]|AMBETTER [293000]|768.5||||768.5|0|584.06|153.7
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|299.1|584.06|153.7
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|0|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|768.5||||768.5|384.25|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|768.5||||768.5|299.1|584.06|153.7
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|0|584.06|153.7
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|553.32|584.06|153.7
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|584.06|153.7
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|384.25|584.06|153.7
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 TRADITIONAL OF TEXAS [115503]|768.5||||768.5|584.06|584.06|153.7
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|299.1|584.06|153.7
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|0|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|768.5||||768.5|530.27|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|CIGNA [1260]|CIGNA PPO [126025]|768.5||||768.5|307.4|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|768.5||||768.5|384.25|584.06|153.7
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|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|768.5||||768.5|384.25|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|768.5||||768.5|530.27|584.06|153.7
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|0|584.06|153.7
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|584.06|153.7
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|299.1|584.06|153.7
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|0|584.06|153.7
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|584.06|153.7
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|299.1|584.06|153.7
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|584.06|153.7
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|299.1|584.06|153.7
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|153.7|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|TML [1980]|TML [198000]|768.5||||768.5|530.27|584.06|153.7
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|299.1|584.06|153.7
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|384.25|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UNICARE [2040]|UNICARE [204000]|768.5||||768.5|384.25|584.06|153.7
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|384.25|584.06|153.7
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|WEB TPA [2115]|WEB TPA [211500]|768.5||||768.5|530.27|584.06|153.7
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|0|584.06|153.7
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|0|584.06|153.7
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]|TML WC [212537]|768.5||||768.5|384.25|584.06|153.7
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AARP [1000]|AARP [100000]|390||||390|195|296.4|78
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|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AETNA [1015]|AETNA [101529]|390||||390|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AMBETTER [2930]|AMBETTER [293000]|390||||390|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|390||||390|151.79|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|390||||390|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|390||||390|195|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|390||||390|151.79|296.4|78
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|0|296.4|78
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|280.8|296.4|78
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|296.4|78
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|195|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|390||||390|296.4|296.4|78
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|151.79|296.4|78
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|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|390||||390|269.1|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|CIGNA [1260]|CIGNA PPO [126025]|390||||390|156|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|390||||390|195|296.4|78
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|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|390||||390|195|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|390||||390|269.1|296.4|78
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|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|390||||390|0|296.4|78
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|151.79|296.4|78
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|0|296.4|78
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|296.4|78
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|151.79|296.4|78
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|296.4|78
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|151.79|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|Self-pay|Self-pay|390||||390|78|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|TML [1980]|TML [198000]|390||||390|269.1|296.4|78
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|151.79|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|390||||390|195|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UNICARE [2040]|UNICARE [204000]|390||||390|195|296.4|78
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|195|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|WEB TPA [2115]|WEB TPA [211500]|390||||390|269.1|296.4|78
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|0|296.4|78
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|0|296.4|78
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|WORKER'S COMP [2125]|TML WC [212537]|390||||390|195|296.4|78
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|1451.21||||1451.21|725.61|1102.92|290.24
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]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1451.21||||1451.21|564.81|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1451.21||||1451.21|564.81|1102.92|290.24
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]|1451.21||||1451.21|0|1102.92|290.24
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]|1451.21||||1451.21|1044.87|1102.92|290.24
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]|1451.21||||1451.21|725.61|1102.92|290.24
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]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1451.21||||1451.21|1102.92|1102.92|290.24
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]|1451.21||||1451.21|564.81|1102.92|290.24
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]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1451.21||||1451.21|1001.33|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|1451.21||||1451.21|580.48|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1451.21||||1451.21|1001.33|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1451.21||||1451.21|1001.33|1102.92|290.24
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]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1451.21||||1451.21|564.81|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1451.21||||1451.21|0|1102.92|290.24
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]|1451.21||||1451.21|564.81|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1451.21||||1451.21|1001.33|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1451.21||||1451.21|564.81|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|1451.21||||1451.21|290.24|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|1451.21||||1451.21|1001.33|1102.92|290.24
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]|1451.21||||1451.21|564.81|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1451.21||||1451.21|725.61|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|1451.21||||1451.21|1001.33|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1451.21||||1451.21|0|1102.92|290.24
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]|1451.21||||1451.21|0|1102.92|290.24
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|1451.21||||1451.21|725.61|1102.92|290.24
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|1160.28||||1160.28||881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1160.28||||1160.28|580.14|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1160.28||||1160.28|835.4|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1160.28||||1160.28|580.14|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1160.28||||1160.28|580.14|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1160.28||||1160.28|881.81|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|1160.28||||1160.28|464.11|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1160.28||||1160.28||881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1160.28||||1160.28|580.14|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|Self-pay|Self-pay|1160.28||||1160.28|232.06|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|TML [1980]|TML [198000]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1160.28||||1160.28|451.58|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1160.28||||1160.28||881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|1160.28||||1160.28||881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1160.28||||1160.28||881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|1160.28||||1160.28|800.59|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1160.28||||1160.28|0|881.81|232.06
133330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCO C,Y,W-135 VACC 2 OF 2(PF) 5 MCG X3/0.5 ML(FINAL) IM SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|1160.28||||1160.28||881.81|232.06
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.38||||15.38||11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.38||||15.38|7.69|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.38||||15.38|11.07|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.38||||15.38|7.69|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.38||||15.38|7.69|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.38||||15.38|11.69|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.38||||15.38|6.15|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.38||||15.38||11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.38||||15.38|7.69|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|Self-pay|Self-pay|15.38||||15.38|3.08|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.38||||15.38|5.99|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.38||||15.38||11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.38||||15.38||11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.38||||15.38||11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.38||||15.38|10.61|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.38||||15.38|0|11.69|3.08
13358|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.38||||15.38||11.69|3.08
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AARP [1000]|AARP [100000]|257.93||||257.93||196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AETNA [1015]|AETNA [101529]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|257.93||||257.93|100.39|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|257.93||||257.93|128.97|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|257.93||||257.93|100.39|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
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]|257.93||||257.93|185.71|196.03|51.59
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]|257.93||||257.93|128.97|196.03|51.59
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]|257.93||||257.93|128.97|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|257.93||||257.93|196.03|196.03|51.59
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]|257.93||||257.93|100.39|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|257.93||||257.93|177.97|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|257.93||||257.93|103.17|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|257.93||||257.93||196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|257.93||||257.93|177.97|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|257.93||||257.93|128.97|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|257.93||||257.93|177.97|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|257.93||||257.93|0|196.03|51.59
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]|257.93||||257.93|100.39|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|257.93||||257.93|0|196.03|51.59
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]|257.93||||257.93|100.39|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|257.93||||257.93|177.97|196.03|51.59
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]|257.93||||257.93|100.39|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|Self-pay|Self-pay|257.93||||257.93|51.59|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|TML [1980]|TML [198000]|257.93||||257.93|177.97|196.03|51.59
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]|257.93||||257.93|100.39|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|257.93||||257.93||196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNICARE [2040]|UNICARE [204000]|257.93||||257.93||196.03|51.59
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]|257.93||||257.93||196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|257.93||||257.93|177.97|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
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]|257.93||||257.93|0|196.03|51.59
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|257.93||||257.93||196.03|51.59
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|91.88||||91.88||69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMBETTER [2930]|AMBETTER [293000]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|91.88||||91.88|45.94|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|91.88||||91.88|35.76|69.83|18.38
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]|91.88||||91.88|0|69.83|18.38
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]|91.88||||91.88|66.15|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91.88||||91.88|45.94|69.83|18.38
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]|91.88||||91.88|45.94|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|91.88||||91.88|69.83|69.83|18.38
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]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|91.88||||91.88|63.4|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA PPO [126025]|91.88||||91.88|36.75|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|91.88||||91.88||69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|91.88||||91.88|63.4|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|91.88||||91.88|45.94|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|91.88||||91.88|63.4|69.83|18.38
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]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91.88||||91.88|0|69.83|18.38
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]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|91.88||||91.88|63.4|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|Self-pay|Self-pay|91.88||||91.88|18.38|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|TML [1980]|TML [198000]|91.88||||91.88|63.4|69.83|18.38
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]|91.88||||91.88|35.76|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91.88||||91.88||69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNICARE [2040]|UNICARE [204000]|91.88||||91.88||69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91.88||||91.88||69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WEB TPA [2115]|WEB TPA [211500]|91.88||||91.88|63.4|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91.88||||91.88|0|69.83|18.38
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]|91.88||||91.88|0|69.83|18.38
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TML WC [212537]|91.88||||91.88||69.83|18.38
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|5.28||||5.28||4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|3.8|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.28||||5.28|2.64|4.01|1.06
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]|5.28||||5.28|2.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|4.01|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28||4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.28||||5.28|3.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.28||||5.28|3.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|5.28||||5.28|1.06|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.28||||5.28||4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.28||||5.28||4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.28||||5.28||4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28||4.01|1.06
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.83||||11.83||8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.83||||11.83|5.92|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.83||||11.83|4.6|8.99|2.37
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]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.83||||11.83|8.52|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.83||||11.83|5.92|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.83||||11.83|5.92|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.83||||11.83|8.99|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.83||||11.83|8.16|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.83||||11.83|4.73|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.83||||11.83||8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.83||||11.83|8.16|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.83||||11.83|5.92|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.83||||11.83|8.16|8.99|2.37
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]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.83||||11.83|0|8.99|2.37
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]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.83||||11.83|8.16|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|11.83||||11.83|2.37|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.83||||11.83|8.16|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.83||||11.83|4.6|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.83||||11.83||8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.83||||11.83||8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.83||||11.83||8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.83||||11.83|8.16|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.83||||11.83|0|8.99|2.37
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]|11.83||||11.83|0|8.99|2.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.83||||11.83||8.99|2.37
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|27.96||||27.96||21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.96||||27.96|13.98|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.96||||27.96|10.88|21.25|5.59
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]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.96||||27.96|20.13|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.96||||27.96|13.98|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.96||||27.96|13.98|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.96||||27.96|21.25|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.96||||27.96|19.29|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|27.96||||27.96|11.18|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.96||||27.96||21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|27.96||||27.96|19.29|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.96||||27.96|13.98|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.96||||27.96|19.29|21.25|5.59
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]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.96||||27.96|0|21.25|5.59
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]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|27.96||||27.96|19.29|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|27.96||||27.96|5.59|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|27.96||||27.96|19.29|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.96||||27.96|10.88|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.96||||27.96||21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|27.96||||27.96||21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.96||||27.96||21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|27.96||||27.96|19.29|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.96||||27.96|0|21.25|5.59
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]|27.96||||27.96|0|21.25|5.59
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|27.96||||27.96||21.25|5.59
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.67||||2.67||2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.67||||2.67|1.34|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.67||||2.67|1.04|2.03|0.53
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]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.67||||2.67|1.92|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.67||||2.67|1.34|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.67||||2.67|1.34|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.67||||2.67|2.03|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.67||||2.67|1.84|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.67||||2.67|1.07|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.67||||2.67||2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.67||||2.67|1.84|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.67||||2.67|1.34|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.67||||2.67|1.84|2.03|0.53
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]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.67||||2.67|0|2.03|0.53
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]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.67||||2.67|1.84|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.67||||2.67|0.53|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.67||||2.67|1.84|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.67||||2.67|1.04|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.67||||2.67||2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.67||||2.67||2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.67||||2.67||2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.67||||2.67|1.84|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.67||||2.67|0|2.03|0.53
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]|2.67||||2.67|0|2.03|0.53
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.67||||2.67||2.03|0.53
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|208.27||||208.27||158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|208.27||||208.27|104.14|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|208.27||||208.27|81.06|158.29|41.65
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]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|208.27||||208.27|149.95|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|208.27||||208.27|104.14|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|208.27||||208.27|104.14|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|208.27||||208.27|158.29|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|208.27||||208.27|143.71|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|208.27||||208.27|83.31|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|208.27||||208.27||158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|208.27||||208.27|143.71|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|208.27||||208.27|104.14|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|208.27||||208.27|143.71|158.29|41.65
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]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|208.27||||208.27|0|158.29|41.65
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]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|208.27||||208.27|143.71|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|208.27||||208.27|41.65|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|208.27||||208.27|143.71|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|208.27||||208.27|81.06|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|208.27||||208.27||158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|208.27||||208.27||158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|208.27||||208.27||158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|208.27||||208.27|143.71|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|208.27||||208.27|0|158.29|41.65
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]|208.27||||208.27|0|158.29|41.65
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|208.27||||208.27||158.29|41.65
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.79||||1.79||1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.79||||1.79|0.7|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.79||||1.79|0.9|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.79||||1.79|0.7|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
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]|1.79||||1.79|1.29|1.36|0.36
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]|1.79||||1.79|0.9|1.36|0.36
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]|1.79||||1.79|0.9|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.79||||1.79|1.36|1.36|0.36
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]|1.79||||1.79|0.7|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.79||||1.79|1.24|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.79||||1.79|0.72|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.79||||1.79||1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.79||||1.79|1.24|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.79||||1.79|0.9|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.79||||1.79|1.24|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.79||||1.79|0|1.36|0.36
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]|1.79||||1.79|0.7|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.79||||1.79|0|1.36|0.36
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]|1.79||||1.79|0.7|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.79||||1.79|1.24|1.36|0.36
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]|1.79||||1.79|0.7|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|1.79||||1.79|0.36|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.79||||1.79|1.24|1.36|0.36
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]|1.79||||1.79|0.7|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.79||||1.79||1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.79||||1.79||1.36|0.36
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]|1.79||||1.79||1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.79||||1.79|1.24|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
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]|1.79||||1.79|0|1.36|0.36
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.79||||1.79||1.36|0.36
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AARP [1000]|AARP [100000]|1102.2||||1102.2||837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AETNA [1015]|AETNA [101529]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AMBETTER [2930]|AMBETTER [293000]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1102.2||||1102.2|551.1|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1102.2||||1102.2|793.58|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1102.2||||1102.2|551.1|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1102.2||||1102.2|551.1|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1102.2||||1102.2|837.67|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|1102.2||||1102.2|440.88|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1102.2||||1102.2||837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1102.2||||1102.2|551.1|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|Self-pay|Self-pay|1102.2||||1102.2|220.44|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|TML [1980]|TML [198000]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1102.2||||1102.2|428.98|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1102.2||||1102.2||837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|UNICARE [2040]|UNICARE [204000]|1102.2||||1102.2||837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1102.2||||1102.2||837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|WEB TPA [2115]|WEB TPA [211500]|1102.2||||1102.2|760.52|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1102.2||||1102.2|0|837.67|220.44
14123|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|1102.2||||1102.2||837.67|220.44
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AARP [1000]|AARP [100000]|528.07||||528.07||401.33|105.61
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]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AETNA [1015]|AETNA [101529]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AMBETTER [2930]|AMBETTER [293000]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528.07||||528.07|205.52|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528.07||||528.07|264.04|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528.07||||528.07|205.52|401.33|105.61
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]|528.07||||528.07|0|401.33|105.61
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]|528.07||||528.07|380.21|401.33|105.61
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]|528.07||||528.07|264.04|401.33|105.61
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]|528.07||||528.07|264.04|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528.07||||528.07|401.33|401.33|105.61
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]|528.07||||528.07|205.52|401.33|105.61
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]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528.07||||528.07|364.37|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|CIGNA [1260]|CIGNA PPO [126025]|528.07||||528.07|211.23|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528.07||||528.07||401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|528.07||||528.07|364.37|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528.07||||528.07|264.04|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528.07||||528.07|364.37|401.33|105.61
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]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528.07||||528.07|205.52|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528.07||||528.07|0|401.33|105.61
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]|528.07||||528.07|205.52|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528.07||||528.07|364.37|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528.07||||528.07|205.52|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|Self-pay|Self-pay|528.07||||528.07|105.61|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|TML [1980]|TML [198000]|528.07||||528.07|364.37|401.33|105.61
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]|528.07||||528.07|205.52|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528.07||||528.07||401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UNICARE [2040]|UNICARE [204000]|528.07||||528.07||401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528.07||||528.07||401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|WEB TPA [2115]|WEB TPA [211500]|528.07||||528.07|364.37|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528.07||||528.07|0|401.33|105.61
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]|528.07||||528.07|0|401.33|105.61
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|WORKER'S COMP [2125]|TML WC [212537]|528.07||||528.07||401.33|105.61
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AARP [1000]|AARP [100000]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AETNA [1015]|AETNA [101529]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|1.07|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|114.05|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|120.38|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|1.07|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|Self-pay|Self-pay|158.4||||158.4|31.68|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|TML [1980]|TML [198000]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|61.65|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|UNICARE [2040]|UNICARE [204000]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4|79.2|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4|0|120.38|1.07
1446|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION|10,000 mg|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4|79.2|120.38|1.07
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AARP [1000]|AARP [100000]|462||||462||351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMBETTER [2930]|AMBETTER [293000]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|462||||462|231|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|462||||462|179.81|351.12|92.4
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]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|462||||462|332.64|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|462||||462|231|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|462||||462|231|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|462||||462|351.12|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|462||||462|318.78|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA [1260]|CIGNA PPO [126025]|462||||462|184.8|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|462||||462||351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|462||||462|318.78|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|462||||462|231|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|462||||462|318.78|351.12|92.4
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]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|462||||462|0|351.12|92.4
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]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|462||||462|318.78|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|Self-pay|Self-pay|462||||462|92.4|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|TML [1980]|TML [198000]|462||||462|318.78|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|462||||462|179.81|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|462||||462||351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNICARE [2040]|UNICARE [204000]|462||||462||351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|462||||462||351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WEB TPA [2115]|WEB TPA [211500]|462||||462|318.78|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|462||||462|0|351.12|92.4
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]|462||||462|0|351.12|92.4
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WORKER'S COMP [2125]|TML WC [212537]|462||||462||351.12|92.4
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.12||||21.12|1.07|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|15.21|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.12||||21.12|16.05|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|21.12||||21.12|8.45|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.12||||21.12|1.07|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|21.12||||21.12|4.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|8.22|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12|10.56|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|21.12||||21.12|14.57|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12|0|16.05|1.07
1448|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|21.12||||21.12|10.56|16.05|1.07
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.12||||3.12||2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.12||||3.12|1.56|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.12||||3.12|1.21|2.37|0.62
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]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.12||||3.12|2.25|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.12||||3.12|1.56|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.12||||3.12|1.56|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.12||||3.12|2.37|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.12||||3.12|2.15|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|3.12||||3.12|1.25|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.12||||3.12||2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.12||||3.12|2.15|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.12||||3.12|1.56|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.12||||3.12|2.15|2.37|0.62
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]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.12||||3.12|0|2.37|0.62
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]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.12||||3.12|2.15|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.12||||3.12|0.62|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|3.12||||3.12|2.15|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.12||||3.12|1.21|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.12||||3.12||2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|3.12||||3.12||2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.12||||3.12||2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|3.12||||3.12|2.15|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.12||||3.12|0|2.37|0.62
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]|3.12||||3.12|0|2.37|0.62
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|3.12||||3.12||2.37|0.62
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|7.49||||7.49||5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.49||||7.49|3.75|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.49||||7.49|5.39|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.49||||7.49|3.75|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.49||||7.49|3.75|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.49||||7.49|5.69|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.49||||7.49|3|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.49||||7.49||5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.49||||7.49|3.75|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|7.49||||7.49|1.5|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.49||||7.49|2.92|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.49||||7.49||5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.49||||7.49||5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.49||||7.49||5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.49||||7.49|5.17|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.49||||7.49|0|5.69|1.5
14628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.49||||7.49||5.69|1.5
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.02||||1.02||0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.02||||1.02|0.51|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.02||||1.02|0.4|0.78|0.2
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]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.02||||1.02|0.73|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.02||||1.02|0.51|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.02||||1.02|0.51|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.02||||1.02|0.78|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.02||||1.02|0.7|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.02||||1.02|0.41|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.02||||1.02||0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.02||||1.02|0.7|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.02||||1.02|0.51|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.02||||1.02|0.7|0.78|0.2
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]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.02||||1.02|0|0.78|0.2
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]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.02||||1.02|0.7|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.02||||1.02|0.2|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.02||||1.02|0.7|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.02||||1.02|0.4|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.02||||1.02||0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.02||||1.02||0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.02||||1.02||0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.02||||1.02|0.7|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.02||||1.02|0|0.78|0.2
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]|1.02||||1.02|0|0.78|0.2
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.02||||1.02||0.78|0.2
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AARP [1000]|AARP [100000]|38.59||||38.59||29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AETNA [1015]|AETNA [101529]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMBETTER [2930]|AMBETTER [293000]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.59||||38.59|2.47|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.59||||38.59|27.78|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.59||||38.59|19.3|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.59||||38.59|19.3|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.59||||38.59|29.33|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|CIGNA [1260]|CIGNA PPO [126025]|38.59||||38.59|15.44|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.59||||38.59||29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.59||||38.59|2.47|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|Self-pay|Self-pay|38.59||||38.59|7.72|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|TML [1980]|TML [198000]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.59||||38.59|15.02|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.59||||38.59||29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UNICARE [2040]|UNICARE [204000]|38.59||||38.59||29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.59||||38.59||29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WEB TPA [2115]|WEB TPA [211500]|38.59||||38.59|26.63|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.59||||38.59|0|29.33|2.47
1465|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION|750 mg|WORKER'S COMP [2125]|TML WC [212537]|38.59||||38.59||29.33|2.47
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.58||||2.58||1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.58||||2.58|1.29|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.58||||2.58|1.86|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.58||||2.58|1.29|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.58||||2.58|1.29|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.58||||2.58|1.96|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.58||||2.58|1.03|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.58||||2.58||1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.58||||2.58|1.29|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|Self-pay|Self-pay|2.58||||2.58|0.52|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.58||||2.58|1|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.58||||2.58||1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.58||||2.58||1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.58||||2.58||1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.58||||2.58|1.78|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.58||||2.58|0|1.96|0.52
14778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE MICRONIZED 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.58||||2.58||1.96|0.52
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.81||||9.81||7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.81||||9.81|4.91|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.81||||9.81|7.06|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.81||||9.81|4.91|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.81||||9.81|4.91|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.81||||9.81|7.46|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.81||||9.81|3.92|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.81||||9.81||7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.81||||9.81|4.91|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|9.81||||9.81|1.96|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.81||||9.81|3.82|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.81||||9.81||7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.81||||9.81||7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.81||||9.81||7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.81||||9.81|6.77|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.81||||9.81|0|7.46|1.96
14793|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.81||||9.81||7.46|1.96
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|36.57||||36.57||27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.57||||36.57|18.29|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.57||||36.57|14.23|27.79|7.31
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]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.57||||36.57|26.33|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.57||||36.57|18.29|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.57||||36.57|18.29|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.57||||36.57|27.79|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.57||||36.57|25.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|36.57||||36.57|14.63|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.57||||36.57||27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|36.57||||36.57|25.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.57||||36.57|18.29|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.57||||36.57|25.23|27.79|7.31
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]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.57||||36.57|0|27.79|7.31
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]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|36.57||||36.57|25.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|36.57||||36.57|7.31|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|36.57||||36.57|25.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.57||||36.57|14.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.57||||36.57||27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|36.57||||36.57||27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.57||||36.57||27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|36.57||||36.57|25.23|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.57||||36.57|0|27.79|7.31
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]|36.57||||36.57|0|27.79|7.31
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|36.57||||36.57||27.79|7.31
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]|105.6||||105.6||80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|0|80.26|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|AMBETTER [2930]|AMBETTER [293000]|105.6||||105.6|0|80.26|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]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6|0|80.26|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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.6||||105.6|0.03|80.26|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 MEDICAID [1165]|BCBS MEDICAID [116504]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|76.03|80.26|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]|105.6||||105.6|52.8|80.26|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]|105.6||||105.6|52.8|80.26|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 TRADITIONAL OF TEXAS [115503]|105.6||||105.6|80.26|80.26|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]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6|0|80.26|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 - GREAT WEST [126009]|105.6||||105.6|72.86|80.26|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 PPO [126025]|105.6||||105.6|42.24|80.26|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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.6||||105.6||80.26|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]|105.6||||105.6|72.86|80.26|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.6||||105.6|0.03|80.26|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.6||||105.6|72.86|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6|72.86|80.26|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]|105.6||||105.6|41.1|80.26|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|105.6||||105.6|21.12|80.26|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|TML [1980]|TML [198000]|105.6||||105.6|72.86|80.26|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]|105.6||||105.6|41.1|80.26|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]|105.6||||105.6||80.26|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|UNICARE [2040]|UNICARE [204000]|105.6||||105.6||80.26|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]|105.6||||105.6||80.26|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|WEB TPA [2115]|WEB TPA [211500]|105.6||||105.6|72.86|80.26|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]|105.6||||105.6|0|80.26|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]|105.6||||105.6|0|80.26|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]|TML WC [212537]|105.6||||105.6||80.26|0.03
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|17.82||||17.82||13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.82||||17.82|8.91|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.82||||17.82|12.83|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.82||||17.82|8.91|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.82||||17.82|8.91|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.82||||17.82|13.54|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|17.82||||17.82|7.13|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.82||||17.82||13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.82||||17.82|8.91|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|Self-pay|Self-pay|17.82||||17.82|3.56|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.82||||17.82|6.94|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.82||||17.82||13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|17.82||||17.82||13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.82||||17.82||13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|17.82||||17.82|12.3|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.82||||17.82|0|13.54|3.56
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|17.82||||17.82||13.54|3.56
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.49||||8.49||6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.49||||8.49|0.62|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.49||||8.49|3.3|6.45|0.62
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]|8.49||||8.49|0|6.45|0.62
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]|8.49||||8.49|6.11|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.49||||8.49|4.25|6.45|0.62
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]|8.49||||8.49|4.25|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.49||||8.49|6.45|6.45|0.62
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]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.49||||8.49|5.86|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|8.49||||8.49|3.4|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.49||||8.49||6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.49||||8.49|5.86|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.49||||8.49|0.62|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.49||||8.49|5.86|6.45|0.62
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]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.49||||8.49|0|6.45|0.62
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]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.49||||8.49|5.86|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.49||||8.49|1.7|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|8.49||||8.49|5.86|6.45|0.62
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]|8.49||||8.49|3.3|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.49||||8.49||6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|8.49||||8.49||6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.49||||8.49||6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|8.49||||8.49|5.86|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.49||||8.49|0|6.45|0.62
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]|8.49||||8.49|0|6.45|0.62
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|8.49||||8.49||6.45|0.62
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|23.4||||23.4||17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.4||||23.4|11.7|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.4||||23.4|9.11|17.78|4.68
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]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.4||||23.4|16.85|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.4||||23.4|11.7|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.4||||23.4|11.7|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.4||||23.4|17.78|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.4||||23.4|16.15|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|23.4||||23.4|9.36|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.4||||23.4||17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|23.4||||23.4|16.15|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.4||||23.4|11.7|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.4||||23.4|16.15|17.78|4.68
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]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.4||||23.4|0|17.78|4.68
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]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|23.4||||23.4|16.15|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|23.4||||23.4|4.68|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|23.4||||23.4|16.15|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.4||||23.4|9.11|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.4||||23.4||17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|23.4||||23.4||17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.4||||23.4||17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|23.4||||23.4|16.15|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.4||||23.4|0|17.78|4.68
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]|23.4||||23.4|0|17.78|4.68
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|23.4||||23.4||17.78|4.68
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AARP [1000]|AARP [100000]|1684.98||||1684.98||1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1684.98||||1684.98|0.72|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1684.98||||1684.98|1213.19|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1684.98||||1684.98|842.49|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1684.98||||1684.98|842.49|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1684.98||||1684.98|1280.58|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|1684.98||||1684.98|673.99|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1684.98||||1684.98||1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1684.98||||1684.98|0.72|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|Self-pay|Self-pay|1684.98||||1684.98|337|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|TML [1980]|TML [198000]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1684.98||||1684.98|655.79|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1684.98||||1684.98||1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|1684.98||||1684.98||1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1684.98||||1684.98||1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|1684.98||||1684.98|1162.64|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1684.98||||1684.98|0|1280.58|0.72
15330|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE (DIAGNOSTIC) 3 MG/ML INTRAVENOUS SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|1684.98||||1684.98||1280.58|0.72
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]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|43.17||||43.17|0|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|43.17||||43.17|21.59|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|43.17||||43.17|21.59|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|43.17||||43.17|16.8|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|31.08|32.81|8.63
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]|43.17||||43.17|31.08|32.81|8.63
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]|43.17||||43.17|21.59|32.81|8.63
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]|43.17||||43.17|21.59|32.81|8.63
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]|43.17||||43.17|21.59|32.81|8.63
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]|43.17||||43.17|21.59|32.81|8.63
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 TRADITIONAL OF TEXAS [115503]|43.17||||43.17|32.81|32.81|8.63
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 TRADITIONAL OF TEXAS [115503]|43.17||||43.17|32.81|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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 - GREAT WEST [126009]|43.17||||43.17|29.79|32.81|8.63
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 - GREAT WEST [126009]|43.17||||43.17|29.79|32.81|8.63
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 PPO [126025]|43.17||||43.17|17.27|32.81|8.63
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 PPO [126025]|43.17||||43.17|17.27|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|43.17||||43.17||32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|29.79|32.81|8.63
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|43.17||||43.17|21.59|32.81|8.63
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|43.17||||43.17|21.59|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|43.17||||43.17|29.79|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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|43.17||||43.17|8.63|32.81|8.63
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|43.17||||43.17|8.63|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|43.17||||43.17|29.79|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17|16.8|32.81|8.63
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]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17||32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|43.17||||43.17||32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17||32.81|8.63
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]|43.17||||43.17||32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|43.17||||43.17|29.79|32.81|8.63
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|43.17||||43.17|29.79|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|43.17||||43.17|0|32.81|8.63
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]|TML WC [212537]|43.17||||43.17||32.81|8.63
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]|TML WC [212537]|43.17||||43.17||32.81|8.63
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AARP [1000]|AARP [100000]|988.28||||988.28||751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AETNA [1015]|AETNA [101529]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMBETTER [2930]|AMBETTER [293000]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|988.28||||988.28|494.14|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|988.28||||988.28|384.64|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|711.56|751.09|197.66
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]|988.28||||988.28|494.14|751.09|197.66
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]|988.28||||988.28|494.14|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|988.28||||988.28|751.09|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|988.28||||988.28|681.91|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA [1260]|CIGNA PPO [126025]|988.28||||988.28|395.31|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|988.28||||988.28||751.09|197.66
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]|988.28||||988.28|681.91|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|988.28||||988.28|494.14|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|988.28||||988.28|681.91|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|988.28||||988.28|681.91|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|Self-pay|Self-pay|988.28||||988.28|197.66|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|TML [1980]|TML [198000]|988.28||||988.28|681.91|751.09|197.66
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]|988.28||||988.28|384.64|751.09|197.66
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]|988.28||||988.28||751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNICARE [2040]|UNICARE [204000]|988.28||||988.28||751.09|197.66
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]|988.28||||988.28||751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WEB TPA [2115]|WEB TPA [211500]|988.28||||988.28|681.91|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
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]|988.28||||988.28|0|751.09|197.66
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WORKER'S COMP [2125]|TML WC [212537]|988.28||||988.28||751.09|197.66
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.72||||1.72||1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.72||||1.72|0.86|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.72||||1.72|0.67|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|1.24|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.72||||1.72|0.86|1.31|0.34
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]|1.72||||1.72|0.86|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.72||||1.72|1.31|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.72||||1.72|1.19|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.72||||1.72|0.69|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.72||||1.72||1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.72||||1.72|1.19|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.72||||1.72|0.86|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.72||||1.72|1.19|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.72||||1.72|1.19|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.72||||1.72|0.34|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.72||||1.72|1.19|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.72||||1.72||1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.72||||1.72||1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.72||||1.72||1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.72||||1.72|1.19|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.72||||1.72||1.31|0.34
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]|198||||198|99|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|0|150.48|0.42
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|AMBETTER [2930]|AMBETTER [293000]|198||||198|0|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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]|198||||198|0|150.48|0.42
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|0.42|150.48|0.42
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 MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|77.06|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|142.56|150.48|0.42
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]|198||||198|99|150.48|0.42
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]|198||||198|99|150.48|0.42
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 TRADITIONAL OF TEXAS [115503]|198||||198|150.48|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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]|198||||198|0|150.48|0.42
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 - GREAT WEST [126009]|198||||198|136.62|150.48|0.42
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 PPO [126025]|198||||198|79.2|150.48|0.42
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198|99|150.48|0.42
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]|198||||198|136.62|150.48|0.42
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|0.42|150.48|0.42
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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]|198||||198|136.62|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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|198||||198|39.6|150.48|0.42
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|TML [1980]|TML [198000]|198||||198|136.62|150.48|0.42
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]|198||||198|77.06|150.48|0.42
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]|198||||198|99|150.48|0.42
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|UNICARE [2040]|UNICARE [204000]|198||||198|99|150.48|0.42
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]|198||||198|99|150.48|0.42
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|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|198||||198|0|150.48|0.42
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]|TML WC [212537]|198||||198|99|150.48|0.42
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]|72.6||||72.6|36.3|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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|AMBETTER [2930]|AMBETTER [293000]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72.6||||72.6|0.42|55.18|0.42
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 MEDICAID [1165]|BCBS MEDICAID [116504]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|52.27|55.18|0.42
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]|72.6||||72.6|36.3|55.18|0.42
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]|72.6||||72.6|36.3|55.18|0.42
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 TRADITIONAL OF TEXAS [115503]|72.6||||72.6|55.18|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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 - GREAT WEST [126009]|72.6||||72.6|50.09|55.18|0.42
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 PPO [126025]|72.6||||72.6|29.04|55.18|0.42
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72.6||||72.6|36.3|55.18|0.42
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]|72.6||||72.6|50.09|55.18|0.42
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72.6||||72.6|0.42|55.18|0.42
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72.6||||72.6|50.09|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|50.09|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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|72.6||||72.6|14.52|55.18|0.42
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|TML [1980]|TML [198000]|72.6||||72.6|50.09|55.18|0.42
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]|72.6||||72.6|28.26|55.18|0.42
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]|72.6||||72.6|36.3|55.18|0.42
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|UNICARE [2040]|UNICARE [204000]|72.6||||72.6|36.3|55.18|0.42
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]|72.6||||72.6|36.3|55.18|0.42
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|WEB TPA [2115]|WEB TPA [211500]|72.6||||72.6|50.09|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|72.6||||72.6|0|55.18|0.42
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]|TML WC [212537]|72.6||||72.6|36.3|55.18|0.42
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|382.28||||382.28|14.96|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382.28||||382.28|275.24|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|382.28||||382.28|290.53|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|382.28||||382.28|152.91|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|382.28||||382.28|14.96|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|382.28||||382.28|76.46|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382.28||||382.28|148.78|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382.28||||382.28|191.14|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|382.28||||382.28|263.77|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382.28||||382.28|0|290.53|14.96
15852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 1 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|382.28||||382.28|191.14|290.53|14.96
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|247.5||||247.5||188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|247.5||||247.5|123.75|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|247.5||||247.5|96.33|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|178.2|188.1|49.5
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]|247.5||||247.5|123.75|188.1|49.5
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]|247.5||||247.5|123.75|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|247.5||||247.5|188.1|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|247.5||||247.5|170.78|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|247.5||||247.5|99|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|247.5||||247.5||188.1|49.5
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]|247.5||||247.5|170.78|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|247.5||||247.5|123.75|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|247.5||||247.5|170.78|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|247.5||||247.5|170.78|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|Self-pay|Self-pay|247.5||||247.5|49.5|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|TML [1980]|TML [198000]|247.5||||247.5|170.78|188.1|49.5
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]|247.5||||247.5|96.33|188.1|49.5
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]|247.5||||247.5||188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UNICARE [2040]|UNICARE [204000]|247.5||||247.5||188.1|49.5
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]|247.5||||247.5||188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|247.5||||247.5|170.78|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
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]|247.5||||247.5|0|188.1|49.5
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|247.5||||247.5||188.1|49.5
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|75.63||||75.63||57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.63||||75.63|37.82|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.63||||75.63|29.44|57.48|15.13
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]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.63||||75.63|54.45|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.63||||75.63|37.82|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.63||||75.63|37.82|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.63||||75.63|57.48|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.63||||75.63|52.18|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|75.63||||75.63|30.25|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.63||||75.63||57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|75.63||||75.63|52.18|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.63||||75.63|37.82|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.63||||75.63|52.18|57.48|15.13
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]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.63||||75.63|0|57.48|15.13
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]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|75.63||||75.63|52.18|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|75.63||||75.63|15.13|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|75.63||||75.63|52.18|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.63||||75.63|29.44|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.63||||75.63||57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|75.63||||75.63||57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.63||||75.63||57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|75.63||||75.63|52.18|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.63||||75.63|0|57.48|15.13
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]|75.63||||75.63|0|57.48|15.13
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|75.63||||75.63||57.48|15.13
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|181.07||||181.07||137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.07||||181.07|90.54|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.07||||181.07|130.37|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.07||||181.07|90.54|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.07||||181.07|90.54|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.07||||181.07|137.61|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|181.07||||181.07|72.43|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.07||||181.07||137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.07||||181.07|90.54|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|Self-pay|Self-pay|181.07||||181.07|36.21|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|TML [1980]|TML [198000]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.07||||181.07|70.47|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.07||||181.07||137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|181.07||||181.07||137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.07||||181.07||137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|181.07||||181.07|124.94|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.07||||181.07|0|137.61|36.21
15950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.25 % SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|181.07||||181.07||137.61|36.21
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AARP [1000]|AARP [100000]|475.2||||475.2||361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AETNA [1015]|AETNA [101529]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AMBETTER [2930]|AMBETTER [293000]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|475.2||||475.2|237.6|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|475.2||||475.2|184.95|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|475.2||||475.2|342.14|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|475.2||||475.2|237.6|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|475.2||||475.2|237.6|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|475.2||||475.2|361.15|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|475.2||||475.2|327.89|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA PPO [126025]|475.2||||475.2|190.08|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|475.2||||475.2||361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|475.2||||475.2|327.89|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|475.2||||475.2|237.6|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|475.2||||475.2|327.89|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|475.2||||475.2|327.89|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|Self-pay|Self-pay|475.2||||475.2|95.04|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|TML [1980]|TML [198000]|475.2||||475.2|327.89|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|475.2||||475.2|184.95|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|475.2||||475.2||361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UNICARE [2040]|UNICARE [204000]|475.2||||475.2||361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|475.2||||475.2||361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|WEB TPA [2115]|WEB TPA [211500]|475.2||||475.2|327.89|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|475.2||||475.2|0|361.15|95.04
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]|475.2||||475.2|0|361.15|95.04
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|WORKER'S COMP [2125]|TML WC [212537]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AARP [1000]|AARP [100000]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AETNA [1015]|AETNA [101529]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMBETTER [2930]|AMBETTER [293000]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|475.2||||475.2|237.6|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|475.2||||475.2|342.14|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|475.2||||475.2|237.6|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|475.2||||475.2|237.6|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|475.2||||475.2|361.15|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA PPO [126025]|475.2||||475.2|190.08|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|475.2||||475.2|237.6|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|Self-pay|Self-pay|475.2||||475.2|95.04|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|TML [1980]|TML [198000]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|475.2||||475.2|184.95|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UNICARE [2040]|UNICARE [204000]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|475.2||||475.2||361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WEB TPA [2115]|WEB TPA [211500]|475.2||||475.2|327.89|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|475.2||||475.2|0|361.15|95.04
16071|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 42 MCG (0.06 %) NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TML WC [212537]|475.2||||475.2||361.15|95.04
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]|97.68||||97.68|48.84|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.68||||97.68|0.82|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|70.33|74.24|0.82
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]|97.68||||97.68|48.84|74.24|0.82
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]|97.68||||97.68|48.84|74.24|0.82
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 TRADITIONAL OF TEXAS [115503]|97.68||||97.68|74.24|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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 - GREAT WEST [126009]|97.68||||97.68|67.4|74.24|0.82
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 PPO [126025]|97.68||||97.68|39.07|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.68||||97.68|48.84|74.24|0.82
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]|97.68||||97.68|67.4|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.68||||97.68|0.82|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.68||||97.68|67.4|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|67.4|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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|97.68||||97.68|19.54|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|97.68||||97.68|67.4|74.24|0.82
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]|97.68||||97.68|38.02|74.24|0.82
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]|97.68||||97.68|48.84|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|97.68||||97.68|48.84|74.24|0.82
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]|97.68||||97.68|48.84|74.24|0.82
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|97.68||||97.68|67.4|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|97.68||||97.68|0|74.24|0.82
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]|TML WC [212537]|97.68||||97.68|48.84|74.24|0.82
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AARP [1000]|AARP [100000]|28.46||||28.46||21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AETNA [1015]|AETNA [101529]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMBETTER [2930]|AMBETTER [293000]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.46||||28.46|14.23|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|28.46||||28.46|11.08|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|20.49|21.63|5.69
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]|28.46||||28.46|14.23|21.63|5.69
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]|28.46||||28.46|14.23|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|28.46||||28.46|21.63|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|28.46||||28.46|19.64|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA PPO [126025]|28.46||||28.46|11.38|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.46||||28.46||21.63|5.69
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]|28.46||||28.46|19.64|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.46||||28.46|14.23|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.46||||28.46|19.64|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|28.46||||28.46|19.64|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|Self-pay|Self-pay|28.46||||28.46|5.69|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|TML [1980]|TML [198000]|28.46||||28.46|19.64|21.63|5.69
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]|28.46||||28.46|11.08|21.63|5.69
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]|28.46||||28.46||21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNICARE [2040]|UNICARE [204000]|28.46||||28.46||21.63|5.69
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]|28.46||||28.46||21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WEB TPA [2115]|WEB TPA [211500]|28.46||||28.46|19.64|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
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]|28.46||||28.46|0|21.63|5.69
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TML WC [212537]|28.46||||28.46||21.63|5.69
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|35.09||||35.09||26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AMBETTER [2930]|AMBETTER [293000]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|35.09||||35.09|17.55|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|35.09||||35.09|13.66|26.67|7.02
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]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.09||||35.09|25.26|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.09||||35.09|17.55|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.09||||35.09|17.55|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|35.09||||35.09|26.67|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|35.09||||35.09|24.21|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA [1260]|CIGNA PPO [126025]|35.09||||35.09|14.04|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|35.09||||35.09||26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|35.09||||35.09|24.21|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|35.09||||35.09|17.55|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|35.09||||35.09|24.21|26.67|7.02
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]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.09||||35.09|0|26.67|7.02
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]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|35.09||||35.09|24.21|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|Self-pay|Self-pay|35.09||||35.09|7.02|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|TML [1980]|TML [198000]|35.09||||35.09|24.21|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.09||||35.09|13.66|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.09||||35.09||26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UNICARE [2040]|UNICARE [204000]|35.09||||35.09||26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.09||||35.09||26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|WEB TPA [2115]|WEB TPA [211500]|35.09||||35.09|24.21|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.09||||35.09|0|26.67|7.02
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]|35.09||||35.09|0|26.67|7.02
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|WORKER'S COMP [2125]|TML WC [212537]|35.09||||35.09||26.67|7.02
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.76||||5.76||4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.76||||5.76|2.88|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.76||||5.76|4.15|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.76||||5.76|2.88|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.76||||5.76|2.88|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.76||||5.76|4.38|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.76||||5.76|2.3|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.76||||5.76||4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.76||||5.76|2.88|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|Self-pay|Self-pay|5.76||||5.76|1.15|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.76||||5.76|2.24|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.76||||5.76||4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.76||||5.76||4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.76||||5.76||4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.76||||5.76|3.97|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.76||||5.76|0|4.38|1.15
16357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.76||||5.76||4.38|1.15
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|79.2||||79.2||60.19|2.35
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]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|30.82|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|2.35|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|30.82|60.19|2.35
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]|79.2||||79.2|0|60.19|2.35
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]|79.2||||79.2|57.02|60.19|2.35
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]|79.2||||79.2|39.6|60.19|2.35
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]|79.2||||79.2|39.6|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|60.19|60.19|2.35
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]|79.2||||79.2|30.82|60.19|2.35
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]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2||60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|2.35|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|60.19|2.35
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]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.2||||79.2|30.82|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|0|60.19|2.35
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]|79.2||||79.2|30.82|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.2||||79.2|30.82|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|79.2||||79.2|15.84|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|79.2||||79.2|54.65|60.19|2.35
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]|79.2||||79.2|30.82|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2||60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|79.2||||79.2||60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.2||||79.2||60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.2||||79.2|0|60.19|2.35
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]|79.2||||79.2|0|60.19|2.35
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2||60.19|2.35
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|13.72||||13.72||10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.72||||13.72|6.86|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.72||||13.72|9.88|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.72||||13.72|6.86|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.72||||13.72|6.86|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.72||||13.72|10.43|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.72||||13.72|5.49|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.72||||13.72||10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.72||||13.72|6.86|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|13.72||||13.72|2.74|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.72||||13.72|5.34|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.72||||13.72||10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|13.72||||13.72||10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.72||||13.72||10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.72||||13.72|9.47|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.72||||13.72|0|10.43|2.74
164321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.72||||13.72||10.43|2.74
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|557.8||||557.8||423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|557.8||||557.8|278.9|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|557.8||||557.8|401.62|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|557.8||||557.8|278.9|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|557.8||||557.8|278.9|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|557.8||||557.8|423.93|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|557.8||||557.8|223.12|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|557.8||||557.8||423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|557.8||||557.8|278.9|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|557.8||||557.8|111.56|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|557.8||||557.8|217.1|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|557.8||||557.8||423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|557.8||||557.8||423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|557.8||||557.8||423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|557.8||||557.8|384.88|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|557.8||||557.8|0|423.93|111.56
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|557.8||||557.8||423.93|111.56
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.33||||0.33||0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.33||||0.33|0.17|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.33||||0.33|0.13|0.25|0.07
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]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.33||||0.33|0.24|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.33||||0.33|0.17|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.33||||0.33|0.17|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.33||||0.33|0.25|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.33||||0.33|0.23|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.33||||0.33||0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.33||||0.33|0.23|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.33||||0.33|0.17|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.33||||0.33|0.23|0.25|0.07
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]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.33||||0.33|0|0.25|0.07
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]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.33||||0.33|0.23|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|0.33||||0.33|0.07|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.33||||0.33|0.23|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.33||||0.33|0.13|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.33||||0.33||0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.33||||0.33||0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.33||||0.33||0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.33||||0.33|0.23|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.33||||0.33|0|0.25|0.07
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]|0.33||||0.33|0|0.25|0.07
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.33||||0.33||0.25|0.07
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|849.52||||849.52||645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|849.52||||849.52|424.76|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|849.52||||849.52|611.65|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|849.52||||849.52|424.76|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|849.52||||849.52|424.76|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|849.52||||849.52|645.64|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|849.52||||849.52|339.81|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|849.52||||849.52||645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|849.52||||849.52|424.76|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|849.52||||849.52|169.9|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|849.52||||849.52|330.63|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|849.52||||849.52||645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|849.52||||849.52||645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|849.52||||849.52||645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|849.52||||849.52|586.17|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|849.52||||849.52|0|645.64|169.9
164851|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|849.52||||849.52||645.64|169.9
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AARP [1000]|AARP [100000]|51.22||||51.22||38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AETNA [1015]|AETNA [101529]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMBETTER [2930]|AMBETTER [293000]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.22||||51.22|25.61|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|36.88|38.93|10.24
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]|51.22||||51.22|25.61|38.93|10.24
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]|51.22||||51.22|25.61|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.22||||51.22|38.93|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.22||||51.22|35.34|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|51.22||||51.22|20.49|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.22||||51.22||38.93|10.24
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]|51.22||||51.22|35.34|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.22||||51.22|25.61|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.22||||51.22|35.34|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22|35.34|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|Self-pay|Self-pay|51.22||||51.22|10.24|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|TML [1980]|TML [198000]|51.22||||51.22|35.34|38.93|10.24
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]|51.22||||51.22|19.93|38.93|10.24
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]|51.22||||51.22||38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNICARE [2040]|UNICARE [204000]|51.22||||51.22||38.93|10.24
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]|51.22||||51.22||38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WEB TPA [2115]|WEB TPA [211500]|51.22||||51.22|35.34|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
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]|51.22||||51.22|0|38.93|10.24
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|51.22||||51.22||38.93|10.24
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|56.59||||56.59||43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|56.59||||56.59|28.3|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|56.59||||56.59|22.02|43.01|11.32
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]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.59||||56.59|40.74|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.59||||56.59|28.3|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.59||||56.59|28.3|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|56.59||||56.59|43.01|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|56.59||||56.59|39.05|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|56.59||||56.59|22.64|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|56.59||||56.59||43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|56.59||||56.59|39.05|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|56.59||||56.59|28.3|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|56.59||||56.59|39.05|43.01|11.32
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]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.59||||56.59|0|43.01|11.32
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]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|56.59||||56.59|39.05|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|56.59||||56.59|11.32|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|56.59||||56.59|39.05|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.59||||56.59|22.02|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.59||||56.59||43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|56.59||||56.59||43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.59||||56.59||43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|56.59||||56.59|39.05|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.59||||56.59|0|43.01|11.32
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]|56.59||||56.59|0|43.01|11.32
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|56.59||||56.59||43.01|11.32
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|84.14||||84.14||63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84.14||||84.14|42.07|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84.14||||84.14|32.75|63.95|16.83
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]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.14||||84.14|60.58|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.14||||84.14|42.07|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.14||||84.14|42.07|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84.14||||84.14|63.95|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84.14||||84.14|58.06|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|84.14||||84.14|33.66|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84.14||||84.14||63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|84.14||||84.14|58.06|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84.14||||84.14|42.07|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84.14||||84.14|58.06|63.95|16.83
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]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.14||||84.14|0|63.95|16.83
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]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|84.14||||84.14|58.06|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|84.14||||84.14|16.83|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|84.14||||84.14|58.06|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.14||||84.14|32.75|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.14||||84.14||63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|84.14||||84.14||63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.14||||84.14||63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|84.14||||84.14|58.06|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.14||||84.14|0|63.95|16.83
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]|84.14||||84.14|0|63.95|16.83
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|84.14||||84.14||63.95|16.83
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.76||||12.76||9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.76||||12.76|6.38|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.76||||12.76|4.97|9.7|2.55
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]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.76||||12.76|9.19|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.76||||12.76|6.38|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.76||||12.76|6.38|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.76||||12.76|9.7|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.76||||12.76|8.8|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.76||||12.76|5.1|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.76||||12.76||9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.76||||12.76|8.8|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.76||||12.76|6.38|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.76||||12.76|8.8|9.7|2.55
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]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.76||||12.76|0|9.7|2.55
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]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.76||||12.76|8.8|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|12.76||||12.76|2.55|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.76||||12.76|8.8|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.76||||12.76|4.97|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.76||||12.76||9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.76||||12.76||9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.76||||12.76||9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.76||||12.76|8.8|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.76||||12.76|0|9.7|2.55
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]|12.76||||12.76|0|9.7|2.55
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.76||||12.76||9.7|2.55
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.31||||0.31||0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.31||||0.31|0.16|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.31||||0.31|0.12|0.24|0.06
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]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.31||||0.31|0.22|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.31||||0.31|0.16|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.31||||0.31|0.16|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.31||||0.31|0.24|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.31||||0.31|0.21|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.31||||0.31||0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.31||||0.31|0.21|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.31||||0.31|0.16|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.31||||0.31|0.21|0.24|0.06
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]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.31||||0.31|0|0.24|0.06
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]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.31||||0.31|0.21|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|Self-pay|Self-pay|0.31||||0.31|0.06|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.31||||0.31|0.21|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.31||||0.31|0.12|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.31||||0.31||0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.31||||0.31||0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.31||||0.31||0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.31||||0.31|0.21|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.31||||0.31|0|0.24|0.06
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]|0.31||||0.31|0|0.24|0.06
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.31||||0.31||0.24|0.06
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|93.72||||93.72||71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93.72||||93.72|46.86|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93.72||||93.72|67.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93.72||||93.72|46.86|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93.72||||93.72|46.86|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93.72||||93.72|71.23|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|93.72||||93.72|37.49|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93.72||||93.72||71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93.72||||93.72|46.86|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|93.72||||93.72|18.74|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93.72||||93.72|36.48|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93.72||||93.72||71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|93.72||||93.72||71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93.72||||93.72||71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|93.72||||93.72|64.67|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93.72||||93.72|0|71.23|18.74
168989|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|93.72||||93.72||71.23|18.74
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|9944.75||||9944.75||7558.01|54.72
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]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AMBETTER [2930]|AMBETTER [293000]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9944.75||||9944.75|3870.5|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9944.75||||9944.75|54.72|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9944.75||||9944.75|3870.5|7558.01|54.72
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]|9944.75||||9944.75|0|7558.01|54.72
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]|9944.75||||9944.75|7160.22|7558.01|54.72
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]|9944.75||||9944.75|4972.38|7558.01|54.72
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]|9944.75||||9944.75|4972.38|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9944.75||||9944.75|7558.01|7558.01|54.72
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]|9944.75||||9944.75|3870.5|7558.01|54.72
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]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9944.75||||9944.75|6861.88|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA PPO [126025]|9944.75||||9944.75|4972.38|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9944.75||||9944.75||7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|9944.75||||9944.75|6861.88|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9944.75||||9944.75|54.72|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9944.75||||9944.75|6861.88|7558.01|54.72
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]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9944.75||||9944.75|3870.5|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9944.75||||9944.75|0|7558.01|54.72
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]|9944.75||||9944.75|3870.5|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|9944.75||||9944.75|6861.88|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9944.75||||9944.75|3870.5|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|9944.75||||9944.75|1988.95|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|TML [1980]|TML [198000]|9944.75||||9944.75|6861.88|7558.01|54.72
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]|9944.75||||9944.75|3870.5|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9944.75||||9944.75||7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UNICARE [2040]|UNICARE [204000]|9944.75||||9944.75||7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9944.75||||9944.75||7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|WEB TPA [2115]|WEB TPA [211500]|9944.75||||9944.75|6861.88|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9944.75||||9944.75|0|7558.01|54.72
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]|9944.75||||9944.75|0|7558.01|54.72
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TML WC [212537]|9944.75||||9944.75||7558.01|54.72
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]|16.9||||16.9||12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.9||||16.9|8.45|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|12.17|12.84|3.38
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]|16.9||||16.9|8.45|12.84|3.38
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]|16.9||||16.9|8.45|12.84|3.38
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 TRADITIONAL OF TEXAS [115503]|16.9||||16.9|12.84|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.9||||16.9|11.66|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.9||||16.9|6.76|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.9||||16.9||12.84|3.38
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]|16.9||||16.9|11.66|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.9||||16.9|8.45|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.9||||16.9|11.66|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9|11.66|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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|16.9||||16.9|3.38|12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|16.9||||16.9|11.66|12.84|3.38
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]|16.9||||16.9|6.58|12.84|3.38
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]|16.9||||16.9||12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|16.9||||16.9||12.84|3.38
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]|16.9||||16.9||12.84|3.38
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.9||||16.9|11.66|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|16.9||||16.9|0|12.84|3.38
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]|TML WC [212537]|16.9||||16.9||12.84|3.38
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|8.97||||8.97||6.82|1.79
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]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.97||||8.97|3.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.97||||8.97|4.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.97||||8.97|3.49|6.82|1.79
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]|8.97||||8.97|0|6.82|1.79
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]|8.97||||8.97|6.46|6.82|1.79
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]|8.97||||8.97|4.49|6.82|1.79
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]|8.97||||8.97|4.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.97||||8.97|6.82|6.82|1.79
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]|8.97||||8.97|3.49|6.82|1.79
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]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.97||||8.97|6.19|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.97||||8.97|3.59|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.97||||8.97||6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.97||||8.97|6.19|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.97||||8.97|4.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.97||||8.97|6.19|6.82|1.79
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]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.97||||8.97|3.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.97||||8.97|0|6.82|1.79
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]|8.97||||8.97|3.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.97||||8.97|6.19|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.97||||8.97|3.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|8.97||||8.97|1.79|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|TML [1980]|TML [198000]|8.97||||8.97|6.19|6.82|1.79
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]|8.97||||8.97|3.49|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.97||||8.97||6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.97||||8.97||6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.97||||8.97||6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.97||||8.97|6.19|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.97||||8.97|0|6.82|1.79
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]|8.97||||8.97|0|6.82|1.79
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.97||||8.97||6.82|1.79
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AARP [1000]|AARP [100000]|132180||||132180||100456.8|26436
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|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AETNA [1015]|AETNA [101529]|132180||||132180|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMBETTER [2930]|AMBETTER [293000]|132180||||132180|0|100456.8|26436
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|51444.46|100456.8|26436
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|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132180||||132180|66090|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132180||||132180|51444.46|100456.8|26436
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|0|100456.8|26436
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|95169.6|100456.8|26436
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|100456.8|26436
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|66090|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132180||||132180|100456.8|100456.8|26436
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|51444.46|100456.8|26436
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|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132180||||132180|91204.2|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA [1260]|CIGNA PPO [126025]|132180||||132180|52872|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132180||||132180||100456.8|26436
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|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132180||||132180|66090|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132180||||132180|91204.2|100456.8|26436
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|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132180||||132180|0|100456.8|26436
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|51444.46|100456.8|26436
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|0|100456.8|26436
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|0|100456.8|26436
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|51444.46|100456.8|26436
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|100456.8|26436
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|51444.46|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|Self-pay|Self-pay|132180||||132180|26436|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|TML [1980]|TML [198000]|132180||||132180|91204.2|100456.8|26436
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|51444.46|100456.8|26436
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||100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNICARE [2040]|UNICARE [204000]|132180||||132180||100456.8|26436
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||100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WEB TPA [2115]|WEB TPA [211500]|132180||||132180|91204.2|100456.8|26436
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|0|100456.8|26436
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|0|100456.8|26436
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WORKER'S COMP [2125]|TML WC [212537]|132180||||132180||100456.8|26436
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]|192.38||||192.38||146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMBETTER [2930]|AMBETTER [293000]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|192.38||||192.38|96.19|146.21|38.48
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 MEDICAID [1165]|BCBS MEDICAID [116504]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|138.51|146.21|38.48
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]|192.38||||192.38|96.19|146.21|38.48
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]|192.38||||192.38|96.19|146.21|38.48
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 TRADITIONAL OF TEXAS [115503]|192.38||||192.38|146.21|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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 - GREAT WEST [126009]|192.38||||192.38|132.74|146.21|38.48
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 PPO [126025]|192.38||||192.38|76.95|146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|192.38||||192.38||146.21|38.48
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]|192.38||||192.38|132.74|146.21|38.48
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|192.38||||192.38|96.19|146.21|38.48
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|192.38||||192.38|132.74|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38|132.74|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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|192.38||||192.38|38.48|146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|TML [1980]|TML [198000]|192.38||||192.38|132.74|146.21|38.48
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]|192.38||||192.38|74.87|146.21|38.48
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]|192.38||||192.38||146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNICARE [2040]|UNICARE [204000]|192.38||||192.38||146.21|38.48
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]|192.38||||192.38||146.21|38.48
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WEB TPA [2115]|WEB TPA [211500]|192.38||||192.38|132.74|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|192.38||||192.38|0|146.21|38.48
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]|TML WC [212537]|192.38||||192.38||146.21|38.48
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]|50.27||||50.27||38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMBETTER [2930]|AMBETTER [293000]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.27||||50.27|25.14|38.21|10.05
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 MEDICAID [1165]|BCBS MEDICAID [116504]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|36.19|38.21|10.05
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]|50.27||||50.27|25.14|38.21|10.05
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]|50.27||||50.27|25.14|38.21|10.05
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 TRADITIONAL OF TEXAS [115503]|50.27||||50.27|38.21|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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 - GREAT WEST [126009]|50.27||||50.27|34.69|38.21|10.05
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 PPO [126025]|50.27||||50.27|20.11|38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.27||||50.27||38.21|10.05
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]|50.27||||50.27|34.69|38.21|10.05
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.27||||50.27|25.14|38.21|10.05
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.27||||50.27|34.69|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27|34.69|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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|50.27||||50.27|10.05|38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|TML [1980]|TML [198000]|50.27||||50.27|34.69|38.21|10.05
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]|50.27||||50.27|19.57|38.21|10.05
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]|50.27||||50.27||38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNICARE [2040]|UNICARE [204000]|50.27||||50.27||38.21|10.05
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]|50.27||||50.27||38.21|10.05
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WEB TPA [2115]|WEB TPA [211500]|50.27||||50.27|34.69|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|50.27||||50.27|0|38.21|10.05
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]|TML WC [212537]|50.27||||50.27||38.21|10.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|101.22||||101.22||76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101.22||||101.22|19.57|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101.22||||101.22|39.39|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|72.88|76.93|19.57
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]|101.22||||101.22|50.61|76.93|19.57
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]|101.22||||101.22|50.61|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|101.22||||101.22|76.93|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|101.22||||101.22|69.84|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|101.22||||101.22|40.49|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101.22||||101.22||76.93|19.57
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]|101.22||||101.22|69.84|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101.22||||101.22|19.57|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101.22||||101.22|69.84|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|101.22||||101.22|69.84|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|101.22||||101.22|20.24|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|101.22||||101.22|69.84|76.93|19.57
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]|101.22||||101.22|39.39|76.93|19.57
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]|101.22||||101.22||76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|101.22||||101.22||76.93|19.57
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]|101.22||||101.22||76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|101.22||||101.22|69.84|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
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]|101.22||||101.22|0|76.93|19.57
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|101.22||||101.22||76.93|19.57
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AARP [1000]|AARP [100000]|47.26||||47.26||35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AETNA [1015]|AETNA [101529]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|47.26||||47.26|23.63|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.26||||47.26|34.03|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.26||||47.26|23.63|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.26||||47.26|23.63|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|47.26||||47.26|35.92|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|47.26||||47.26|18.9|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|47.26||||47.26||35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|47.26||||47.26|23.63|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|Self-pay|Self-pay|47.26||||47.26|9.45|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|TML [1980]|TML [198000]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.26||||47.26|18.39|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.26||||47.26||35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|47.26||||47.26||35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.26||||47.26||35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|47.26||||47.26|32.61|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.26||||47.26|0|35.92|9.45
172337|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION FIRVANQ REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|47.26||||47.26||35.92|9.45
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AARP [1000]|AARP [100000]|1848||||1848||1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AETNA [1015]|AETNA [101529]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AMBETTER [2930]|AMBETTER [293000]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1848||||1848|924|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1848||||1848|1330.56|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1848||||1848|924|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1848||||1848|924|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1848||||1848|1404.48|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|CIGNA [1260]|CIGNA PPO [126025]|1848||||1848|739.2|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1848||||1848||1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1848||||1848|924|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|Self-pay|Self-pay|1848||||1848|369.6|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|TML [1980]|TML [198000]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1848||||1848|719.24|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1848||||1848||1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|UNICARE [2040]|UNICARE [204000]|1848||||1848||1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1848||||1848||1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|WEB TPA [2115]|WEB TPA [211500]|1848||||1848|1275.12|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1848||||1848|0|1404.48|369.6
172433|ERX|0250 - PHARMACY-GENERAL|STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION|4 g|WORKER'S COMP [2125]|TML WC [212537]|1848||||1848||1404.48|369.6
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|582.39||||582.39||442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|582.39||||582.39|1.12|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|582.39||||582.39|419.32|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|582.39||||582.39|291.2|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|582.39||||582.39|291.2|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|582.39||||582.39|442.62|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|582.39||||582.39|232.96|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|582.39||||582.39||442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|582.39||||582.39|1.12|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|582.39||||582.39|116.48|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|582.39||||582.39|226.67|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|582.39||||582.39||442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|582.39||||582.39||442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|582.39||||582.39||442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|582.39||||582.39|401.85|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|582.39||||582.39|0|442.62|1.12
173069|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|582.39||||582.39||442.62|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|1455.96||||1455.96||1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1455.96||||1455.96|1.12|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|1048.29|1106.53|1.12
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]|1455.96||||1455.96|727.98|1106.53|1.12
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]|1455.96||||1455.96|727.98|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1455.96||||1455.96|1106.53|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1455.96||||1455.96|1004.61|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|1455.96||||1455.96|582.38|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1455.96||||1455.96||1106.53|1.12
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]|1455.96||||1455.96|1004.61|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1455.96||||1455.96|1.12|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1455.96||||1455.96|1004.61|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96|1004.61|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|1455.96||||1455.96|291.19|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|1455.96||||1455.96|1004.61|1106.53|1.12
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]|1455.96||||1455.96|566.66|1106.53|1.12
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]|1455.96||||1455.96||1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|1455.96||||1455.96||1106.53|1.12
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]|1455.96||||1455.96||1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|1455.96||||1455.96|1004.61|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
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]|1455.96||||1455.96|0|1106.53|1.12
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|1455.96||||1455.96||1106.53|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|5823.84||||5823.84||4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5823.84||||5823.84|1.12|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|4193.16|4426.12|1.12
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]|5823.84||||5823.84|2911.92|4426.12|1.12
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]|5823.84||||5823.84|2911.92|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5823.84||||5823.84|4426.12|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5823.84||||5823.84|4018.45|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|5823.84||||5823.84|2911.92|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5823.84||||5823.84||4426.12|1.12
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]|5823.84||||5823.84|4018.45|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5823.84||||5823.84|1.12|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5823.84||||5823.84|4018.45|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84|4018.45|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|5823.84||||5823.84|1164.77|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|5823.84||||5823.84|4018.45|4426.12|1.12
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]|5823.84||||5823.84|2266.64|4426.12|1.12
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]|5823.84||||5823.84||4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|5823.84||||5823.84||4426.12|1.12
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]|5823.84||||5823.84||4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|5823.84||||5823.84|4018.45|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
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]|5823.84||||5823.84|0|4426.12|1.12
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|5823.84||||5823.84||4426.12|1.12
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|311.7||||311.7||236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|311.7||||311.7|155.85|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311.7||||311.7|224.42|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311.7||||311.7|155.85|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311.7||||311.7|155.85|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|311.7||||311.7|236.89|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|311.7||||311.7|124.68|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|311.7||||311.7||236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|311.7||||311.7|155.85|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|311.7||||311.7|62.34|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311.7||||311.7|121.31|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311.7||||311.7||236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|311.7||||311.7||236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311.7||||311.7||236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|311.7||||311.7|215.07|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|311.7||||311.7|0|236.89|62.34
173085|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|311.7||||311.7|155.85|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|311.7||||311.7|121.31|236.89|62.34
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]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311.7||||311.7|224.42|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311.7||||311.7|155.85|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311.7||||311.7|155.85|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|311.7||||311.7|236.89|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|311.7||||311.7|215.07|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|311.7||||311.7|124.68|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|311.7||||311.7|215.07|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|311.7||||311.7|155.85|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|311.7||||311.7|215.07|236.89|62.34
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]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311.7||||311.7|0|236.89|62.34
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]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|311.7||||311.7|215.07|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|311.7||||311.7|62.34|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|311.7||||311.7|215.07|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311.7||||311.7|121.31|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311.7||||311.7||236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|311.7||||311.7|215.07|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311.7||||311.7|0|236.89|62.34
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]|311.7||||311.7|0|236.89|62.34
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|311.7||||311.7||236.89|62.34
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AARP [1000]|AARP [100000]|132||||132||100.32|0.99
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]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AETNA [1015]|AETNA [101529]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMBETTER [2930]|AMBETTER [293000]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|51.37|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|0.99|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|51.37|100.32|0.99
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]|132||||132|0|100.32|0.99
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]|132||||132|95.04|100.32|0.99
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]|132||||132|66|100.32|0.99
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]|132||||132|66|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|100.32|100.32|0.99
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]|132||||132|51.37|100.32|0.99
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]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132||100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|0.99|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|100.32|0.99
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]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|51.37|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|0|100.32|0.99
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]|132||||132|51.37|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|51.37|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|Self-pay|Self-pay|132||||132|26.4|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|TML [1980]|TML [198000]|132||||132|91.08|100.32|0.99
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]|132||||132|51.37|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132||100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNICARE [2040]|UNICARE [204000]|132||||132||100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132||100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132|0|100.32|0.99
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]|132||||132|0|100.32|0.99
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WORKER'S COMP [2125]|TML WC [212537]|132||||132||100.32|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|264||||264||200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMBETTER [2930]|AMBETTER [293000]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|0.99|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|102.75|200.64|0.99
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]|264||||264|0|200.64|0.99
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]|264||||264|190.08|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|200.64|0.99
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]|264||||264|132|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|200.64|200.64|0.99
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]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264||200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|0.99|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|200.64|0.99
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]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|0|200.64|0.99
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]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|264||||264|52.8|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|TML [1980]|TML [198000]|264||||264|182.16|200.64|0.99
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]|264||||264|102.75|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNICARE [2040]|UNICARE [204000]|264||||264||200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264|0|200.64|0.99
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]|264||||264|0|200.64|0.99
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|264||||264||200.64|0.99
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|1087.82||||1087.82|543.91|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1087.82||||1087.82|543.91|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|783.23|826.74|217.56
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]|1087.82||||1087.82|543.91|826.74|217.56
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]|1087.82||||1087.82|543.91|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1087.82||||1087.82|826.74|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1087.82||||1087.82|750.6|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|1087.82||||1087.82|435.13|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1087.82||||1087.82|543.91|826.74|217.56
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]|1087.82||||1087.82|750.6|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1087.82||||1087.82|543.91|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1087.82||||1087.82|750.6|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|750.6|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|Self-pay|Self-pay|1087.82||||1087.82|217.56|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|TML [1980]|TML [198000]|1087.82||||1087.82|750.6|826.74|217.56
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]|1087.82||||1087.82|423.38|826.74|217.56
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]|1087.82||||1087.82|543.91|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|1087.82||||1087.82|543.91|826.74|217.56
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]|1087.82||||1087.82|543.91|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|1087.82||||1087.82|750.6|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
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]|1087.82||||1087.82|0|826.74|217.56
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|1087.82||||1087.82|543.91|826.74|217.56
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|108.35||||108.35||82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108.35||||108.35|54.18|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.35||||108.35|78.01|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.35||||108.35|54.18|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.35||||108.35|54.18|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108.35||||108.35|82.35|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|108.35||||108.35|43.34|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108.35||||108.35||82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108.35||||108.35|54.18|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|108.35||||108.35|21.67|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.35||||108.35|42.17|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.35||||108.35||82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|108.35||||108.35||82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.35||||108.35||82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|108.35||||108.35|74.76|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.35||||108.35|0|82.35|21.67
174271|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|108.35||||108.35||82.35|21.67
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AARP [1000]|AARP [100000]|392.84||||392.84||298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AETNA [1015]|AETNA [101529]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMBETTER [2930]|AMBETTER [293000]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|392.84||||392.84|196.42|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|392.84||||392.84|282.84|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|392.84||||392.84|196.42|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|392.84||||392.84|196.42|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|392.84||||392.84|298.56|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|CIGNA [1260]|CIGNA PPO [126025]|392.84||||392.84|157.14|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|392.84||||392.84||298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|392.84||||392.84|196.42|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|Self-pay|Self-pay|392.84||||392.84|78.57|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|TML [1980]|TML [198000]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|392.84||||392.84|152.89|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|392.84||||392.84||298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UNICARE [2040]|UNICARE [204000]|392.84||||392.84||298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|392.84||||392.84||298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WEB TPA [2115]|WEB TPA [211500]|392.84||||392.84|271.06|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|392.84||||392.84|0|298.56|78.57
174389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALSAM PERU-CASTOR OIL TOPICAL OINTMENT|60 g|WORKER'S COMP [2125]|TML WC [212537]|392.84||||392.84||298.56|78.57
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.18||||2.18||1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.18||||2.18|1.09|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.18||||2.18|0.85|1.66|0.44
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]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.18||||2.18|1.57|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.18||||2.18|1.09|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.18||||2.18|1.09|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.18||||2.18|1.66|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.18||||2.18|1.5|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.18||||2.18|0.87|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.18||||2.18||1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.18||||2.18|1.5|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.18||||2.18|1.09|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.18||||2.18|1.5|1.66|0.44
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]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.18||||2.18|0|1.66|0.44
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]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.18||||2.18|1.5|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|Self-pay|Self-pay|2.18||||2.18|0.44|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.18||||2.18|1.5|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.18||||2.18|0.85|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.18||||2.18||1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.18||||2.18||1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.18||||2.18||1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.18||||2.18|1.5|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.18||||2.18|0|1.66|0.44
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]|2.18||||2.18|0|1.66|0.44
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.18||||2.18||1.66|0.44
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AARP [1000]|AARP [100000]|105.6||||105.6||80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.6||||105.6|52.8|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.6||||105.6|76.03|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.6||||105.6|52.8|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.6||||105.6|52.8|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|105.6||||105.6|80.26|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|105.6||||105.6|42.24|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.6||||105.6||80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.6||||105.6|52.8|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|Self-pay|Self-pay|105.6||||105.6|21.12|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|TML [1980]|TML [198000]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.6||||105.6|41.1|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.6||||105.6||80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|105.6||||105.6||80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.6||||105.6||80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|105.6||||105.6|72.86|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.6||||105.6|0|80.26|21.12
174910|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 9 MG IODINE/ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|105.6||||105.6||80.26|21.12
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|55806.3||||55806.3||42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55806.3||||55806.3|21719.81|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|55806.3||||55806.3|89.05|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|55806.3||||55806.3|21719.81|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
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]|55806.3||||55806.3|40180.54|42412.79|89.05
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]|55806.3||||55806.3|27903.15|42412.79|89.05
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]|55806.3||||55806.3|27903.15|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|55806.3||||55806.3|42412.79|42412.79|89.05
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]|55806.3||||55806.3|21719.81|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|55806.3||||55806.3|38506.35|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|55806.3||||55806.3|27903.15|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|55806.3||||55806.3||42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|55806.3||||55806.3|38506.35|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|55806.3||||55806.3|89.05|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|55806.3||||55806.3|38506.35|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55806.3||||55806.3|0|42412.79|89.05
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]|55806.3||||55806.3|21719.81|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55806.3||||55806.3|0|42412.79|89.05
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]|55806.3||||55806.3|21719.81|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|55806.3||||55806.3|38506.35|42412.79|89.05
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]|55806.3||||55806.3|21719.81|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|55806.3||||55806.3|11161.26|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|55806.3||||55806.3|38506.35|42412.79|89.05
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]|55806.3||||55806.3|21719.81|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55806.3||||55806.3||42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|55806.3||||55806.3||42412.79|89.05
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]|55806.3||||55806.3||42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|55806.3||||55806.3|38506.35|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
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]|55806.3||||55806.3|0|42412.79|89.05
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|55806.3||||55806.3||42412.79|89.05
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|1463.36||||1463.36||1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1463.36||||1463.36|731.68|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1463.36||||1463.36|1053.62|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1463.36||||1463.36|731.68|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1463.36||||1463.36|731.68|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1463.36||||1463.36|1112.15|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1463.36||||1463.36|585.34|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1463.36||||1463.36||1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1463.36||||1463.36|731.68|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|1463.36||||1463.36|292.67|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1463.36||||1463.36|569.54|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1463.36||||1463.36||1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|1463.36||||1463.36||1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1463.36||||1463.36||1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|1463.36||||1463.36|1009.72|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1463.36||||1463.36|0|1112.15|292.67
175756|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1463.36||||1463.36||1112.15|292.67
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1397.88||||1397.88|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1397.88||||1397.88|1006.47|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1397.88||||1397.88|1062.39|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1397.88||||1397.88|559.15|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1397.88||||1397.88|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1397.88||||1397.88|279.58|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1397.88||||1397.88|964.54|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1397.88||||1397.88|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1397.88||||1397.88|698.94|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMBETTER [2930]|AMBETTER [293000]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2378.64||||2378.64|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2378.64||||2378.64|1712.62|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2378.64||||2378.64|1807.77|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA PPO [126025]|2378.64||||2378.64|951.46|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2378.64||||2378.64|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|2378.64||||2378.64|475.73|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|TML [1980]|TML [198000]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UNICARE [2040]|UNICARE [204000]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WEB TPA [2115]|WEB TPA [211500]|2378.64||||2378.64|1641.26|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2378.64||||2378.64|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TML WC [212537]|2378.64||||2378.64|1189.32|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|865.92||||865.92|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|865.92||||865.92|623.46|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|865.92||||865.92|658.1|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|865.92||||865.92|346.37|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|865.92||||865.92|0.14|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|865.92||||865.92|173.18|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|865.92||||865.92|432.96|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|865.92||||865.92|597.48|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|865.92||||865.92|0|1807.77|0.14
17595|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|865.92||||865.92|432.96|1807.77|0.14
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|192.49||||192.49||146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|192.49||||192.49|96.25|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|192.49||||192.49|138.59|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|192.49||||192.49|96.25|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|192.49||||192.49|96.25|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|192.49||||192.49|146.29|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|192.49||||192.49|77|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|192.49||||192.49||146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|192.49||||192.49|96.25|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|192.49||||192.49|38.5|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|192.49||||192.49|74.92|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|192.49||||192.49||146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|192.49||||192.49||146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|192.49||||192.49||146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|192.49||||192.49|132.82|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|192.49||||192.49|0|146.29|38.5
1767|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|192.49||||192.49||146.29|38.5
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AARP [1000]|AARP [100000]|576||||576||437.76|115.2
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|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AETNA [1015]|AETNA [101529]|576||||576|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AMBETTER [2930]|AMBETTER [293000]|576||||576|0|437.76|115.2
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|224.18|437.76|115.2
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|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|576||||576|288|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|576||||576|224.18|437.76|115.2
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|0|437.76|115.2
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|414.72|437.76|115.2
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|437.76|115.2
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|288|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|576||||576|437.76|437.76|115.2
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|224.18|437.76|115.2
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|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|576||||576|397.44|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|CIGNA [1260]|CIGNA PPO [126025]|576||||576|230.4|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|576||||576||437.76|115.2
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|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|576||||576|288|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|576||||576|397.44|437.76|115.2
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|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|576||||576|0|437.76|115.2
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|224.18|437.76|115.2
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|0|437.76|115.2
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|0|437.76|115.2
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|224.18|437.76|115.2
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|437.76|115.2
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|224.18|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|Self-pay|Self-pay|576||||576|115.2|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|TML [1980]|TML [198000]|576||||576|397.44|437.76|115.2
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|224.18|437.76|115.2
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||437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UNICARE [2040]|UNICARE [204000]|576||||576||437.76|115.2
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||437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|WEB TPA [2115]|WEB TPA [211500]|576||||576|397.44|437.76|115.2
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|0|437.76|115.2
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|0|437.76|115.2
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|WORKER'S COMP [2125]|TML WC [212537]|576||||576||437.76|115.2
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AARP [1000]|AARP [100000]|201.17||||201.17||152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AETNA [1015]|AETNA [101529]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AMBETTER [2930]|AMBETTER [293000]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|201.17||||201.17|100.59|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|201.17||||201.17|144.84|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|201.17||||201.17|100.59|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|201.17||||201.17|100.59|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|201.17||||201.17|152.89|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|201.17||||201.17|80.47|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|201.17||||201.17||152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|201.17||||201.17|100.59|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|Self-pay|Self-pay|201.17||||201.17|40.23|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|TML [1980]|TML [198000]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|201.17||||201.17|78.3|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|201.17||||201.17||152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|UNICARE [2040]|UNICARE [204000]|201.17||||201.17||152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|201.17||||201.17||152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|WEB TPA [2115]|WEB TPA [211500]|201.17||||201.17|138.81|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|201.17||||201.17|0|152.89|40.23
177825|ERX|0250 - PHARMACY-GENERAL|MINERAL OIL, LIGHT STERILE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|201.17||||201.17||152.89|40.23
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AARP [1000]|AARP [100000]|291.25||||291.25||221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AETNA [1015]|AETNA [101529]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AMBETTER [2930]|AMBETTER [293000]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|291.25||||291.25|145.63|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|291.25||||291.25|113.35|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|209.7|221.35|58.25
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]|291.25||||291.25|145.63|221.35|58.25
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]|291.25||||291.25|145.63|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|291.25||||291.25|221.35|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|291.25||||291.25|200.96|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|CIGNA [1260]|CIGNA PPO [126025]|291.25||||291.25|116.5|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|291.25||||291.25||221.35|58.25
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]|291.25||||291.25|200.96|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|291.25||||291.25|145.63|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|291.25||||291.25|200.96|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|PHCS [1780]|PHCS MULTIPLAN [178000]|291.25||||291.25|200.96|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|Self-pay|Self-pay|291.25||||291.25|58.25|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|TML [1980]|TML [198000]|291.25||||291.25|200.96|221.35|58.25
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]|291.25||||291.25|113.35|221.35|58.25
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]|291.25||||291.25||221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UNICARE [2040]|UNICARE [204000]|291.25||||291.25||221.35|58.25
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]|291.25||||291.25||221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|WEB TPA [2115]|WEB TPA [211500]|291.25||||291.25|200.96|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
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]|291.25||||291.25|0|221.35|58.25
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|WORKER'S COMP [2125]|TML WC [212537]|291.25||||291.25||221.35|58.25
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|382.8||||382.8||290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|382.8||||382.8|191.4|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382.8||||382.8|275.62|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382.8||||382.8|191.4|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382.8||||382.8|191.4|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|382.8||||382.8|290.93|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|382.8||||382.8|153.12|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|382.8||||382.8||290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|382.8||||382.8|191.4|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|382.8||||382.8|76.56|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382.8||||382.8|148.99|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382.8||||382.8||290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|382.8||||382.8||290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382.8||||382.8||290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|382.8||||382.8|264.13|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382.8||||382.8|0|290.93|76.56
178774|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|382.8||||382.8||290.93|76.56
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|577.57||||577.57|415.85|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|577.57||||577.57|438.95|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|577.57||||577.57|231.03|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|Self-pay|Self-pay|577.57||||577.57|115.51|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|TML [1980]|TML [198000]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|577.57||||577.57|224.79|438.95|115.51
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]|577.57||||577.57|0|438.95|115.51
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]|577.57||||577.57|415.85|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|577.57||||577.57|288.79|438.95|115.51
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]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|577.57||||577.57|438.95|438.95|115.51
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]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|577.57||||577.57|231.03|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|577.57||||577.57|288.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|577.57||||577.57|398.52|438.95|115.51
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]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|577.57||||577.57|0|438.95|115.51
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]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|Self-pay|Self-pay|577.57||||577.57|115.51|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|TML [1980]|TML [198000]|577.57||||577.57|398.52|438.95|115.51
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]|577.57||||577.57|224.79|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|577.57||||577.57||438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|577.57||||577.57|398.52|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|577.57||||577.57|0|438.95|115.51
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]|577.57||||577.57|0|438.95|115.51
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|577.57||||577.57||438.95|115.51
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AARP [1000]|AARP [100000]|650||||650||494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|650||||650|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|650||||650|325|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|650||||650|252.98|494|130
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|0|494|130
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|468|494|130
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|494|130
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|325|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|650||||650|494|494|130
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|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|650||||650|448.5|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|650||||650|260|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|650||||650||494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|650||||650|448.5|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|650||||650|325|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|650||||650|448.5|494|130
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|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|650||||650|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|650||||650|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|650||||650|0|494|130
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|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|650||||650|448.5|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|650||||650|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|Self-pay|Self-pay|650||||650|130|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|TML [1980]|TML [198000]|650||||650|448.5|494|130
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|252.98|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|650||||650||494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|650||||650||494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|650||||650||494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|650||||650|448.5|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|650||||650|0|494|130
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|0|494|130
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|650||||650||494|130
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.6||||4.6||3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.6||||4.6|2.3|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.6||||4.6|1.79|3.5|0.92
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]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.6||||4.6|3.31|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.6||||4.6|2.3|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.6||||4.6|2.3|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.6||||4.6|3.5|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.6||||4.6|3.17|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.6||||4.6|1.84|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.6||||4.6||3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.6||||4.6|3.17|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.6||||4.6|2.3|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.6||||4.6|3.17|3.5|0.92
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]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.6||||4.6|0|3.5|0.92
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]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.6||||4.6|3.17|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|4.6||||4.6|0.92|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.6||||4.6|3.17|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.6||||4.6|1.79|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.6||||4.6||3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.6||||4.6||3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.6||||4.6||3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.6||||4.6|3.17|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.6||||4.6|0|3.5|0.92
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]|4.6||||4.6|0|3.5|0.92
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.6||||4.6||3.5|0.92
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AARP [1000]|AARP [100000]|283.8||||283.8||215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|283.8||||283.8|141.9|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|283.8||||283.8|204.34|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|283.8||||283.8|141.9|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|283.8||||283.8|141.9|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|283.8||||283.8|215.69|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|283.8||||283.8|113.52|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|283.8||||283.8||215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|283.8||||283.8|141.9|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|Self-pay|Self-pay|283.8||||283.8|56.76|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|TML [1980]|TML [198000]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|283.8||||283.8|110.45|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|283.8||||283.8||215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|283.8||||283.8||215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|283.8||||283.8||215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|283.8||||283.8|195.82|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|283.8||||283.8|0|215.69|56.76
179993|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|283.8||||283.8||215.69|56.76
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.34||||11.34||8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.34||||11.34|5.67|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.34||||11.34|8.16|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.34||||11.34|5.67|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.34||||11.34|5.67|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.34||||11.34|8.62|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.34||||11.34|4.54|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.34||||11.34||8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.34||||11.34|5.67|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|Self-pay|Self-pay|11.34||||11.34|2.27|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.34||||11.34|4.41|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.34||||11.34||8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.34||||11.34||8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.34||||11.34||8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.34||||11.34|7.82|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.34||||11.34|0|8.62|2.27
1802|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE SULFATE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.34||||11.34||8.62|2.27
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AARP [1000]|AARP [100000]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|509.52||||509.52|0.09|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|509.52||||509.52|366.85|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|509.52||||509.52|387.24|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|509.52||||509.52|203.81|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|509.52||||509.52|0.09|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|Self-pay|Self-pay|509.52||||509.52|101.9|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|TML [1980]|TML [198000]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|509.52||||509.52|198.31|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|509.52||||509.52|351.57|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|509.52||||509.52|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|509.52||||509.52|254.76|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AARP [1000]|AARP [100000]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AMBETTER [2930]|AMBETTER [293000]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1019.04||||1019.04|0.09|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1019.04||||1019.04|733.71|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1019.04||||1019.04|774.47|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|CIGNA [1260]|CIGNA PPO [126025]|1019.04||||1019.04|407.62|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1019.04||||1019.04|0.09|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|Self-pay|Self-pay|1019.04||||1019.04|203.81|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|TML [1980]|TML [198000]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1019.04||||1019.04|396.61|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|UNICARE [2040]|UNICARE [204000]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1019.04||||1019.04|509.52|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|WEB TPA [2115]|WEB TPA [211500]|1019.04||||1019.04|703.14|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1019.04||||1019.04|0|774.47|0.09
18192|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION|200 mL|WORKER'S COMP [2125]|TML WC [212537]|1019.04||||1019.04|509.52|774.47|0.09
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|94.93||||94.93||72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|94.93||||94.93|47.47|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|94.93||||94.93|36.95|72.15|18.99
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]|94.93||||94.93|0|72.15|18.99
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]|94.93||||94.93|68.35|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94.93||||94.93|47.47|72.15|18.99
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]|94.93||||94.93|47.47|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|94.93||||94.93|72.15|72.15|18.99
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]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|94.93||||94.93|65.5|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|94.93||||94.93|37.97|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|94.93||||94.93||72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|94.93||||94.93|65.5|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|94.93||||94.93|47.47|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|94.93||||94.93|65.5|72.15|18.99
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]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94.93||||94.93|0|72.15|18.99
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]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|94.93||||94.93|65.5|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|Self-pay|Self-pay|94.93||||94.93|18.99|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|TML [1980]|TML [198000]|94.93||||94.93|65.5|72.15|18.99
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]|94.93||||94.93|36.95|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94.93||||94.93||72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|94.93||||94.93||72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94.93||||94.93||72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|94.93||||94.93|65.5|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94.93||||94.93|0|72.15|18.99
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]|94.93||||94.93|0|72.15|18.99
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|94.93||||94.93||72.15|18.99
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.93||||10.93||8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.93||||10.93|5.47|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.93||||10.93|4.25|8.31|2.19
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]|10.93||||10.93|0|8.31|2.19
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]|10.93||||10.93|7.87|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.93||||10.93|5.47|8.31|2.19
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]|10.93||||10.93|5.47|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.93||||10.93|8.31|8.31|2.19
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]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.93||||10.93|7.54|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.93||||10.93|4.37|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.93||||10.93||8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.93||||10.93|7.54|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.93||||10.93|5.47|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.93||||10.93|7.54|8.31|2.19
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]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.93||||10.93|0|8.31|2.19
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]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.93||||10.93|7.54|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|10.93||||10.93|2.19|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.93||||10.93|7.54|8.31|2.19
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]|10.93||||10.93|4.25|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.93||||10.93||8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.93||||10.93||8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.93||||10.93||8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.93||||10.93|7.54|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.93||||10.93|0|8.31|2.19
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]|10.93||||10.93|0|8.31|2.19
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.93||||10.93||8.31|2.19
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.83||||2.83||2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.83||||2.83|1.42|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.83||||2.83|2.04|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.83||||2.83|1.42|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.83||||2.83|1.42|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.83||||2.83|2.15|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.83||||2.83|1.13|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.83||||2.83||2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.83||||2.83|1.42|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|2.83||||2.83|0.57|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.83||||2.83|1.1|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.83||||2.83||2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.83||||2.83||2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.83||||2.83||2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.83||||2.83|1.95|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.83||||2.83|0|2.15|0.57
18293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TORSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.83||||2.83||2.15|0.57
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]|229.42||||229.42|114.71|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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|AMBETTER [2930]|AMBETTER [293000]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|229.42||||229.42|25.45|174.36|25.45
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 MEDICAID [1165]|BCBS MEDICAID [116504]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|165.18|174.36|25.45
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]|229.42||||229.42|114.71|174.36|25.45
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]|229.42||||229.42|114.71|174.36|25.45
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 TRADITIONAL OF TEXAS [115503]|229.42||||229.42|174.36|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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 - GREAT WEST [126009]|229.42||||229.42|158.3|174.36|25.45
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 PPO [126025]|229.42||||229.42|91.77|174.36|25.45
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|229.42||||229.42|114.71|174.36|25.45
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]|229.42||||229.42|158.3|174.36|25.45
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|229.42||||229.42|25.45|174.36|25.45
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|229.42||||229.42|158.3|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|158.3|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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|229.42||||229.42|45.88|174.36|25.45
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|TML [1980]|TML [198000]|229.42||||229.42|158.3|174.36|25.45
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]|229.42||||229.42|89.29|174.36|25.45
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]|229.42||||229.42|114.71|174.36|25.45
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|UNICARE [2040]|UNICARE [204000]|229.42||||229.42|114.71|174.36|25.45
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]|229.42||||229.42|114.71|174.36|25.45
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|WEB TPA [2115]|WEB TPA [211500]|229.42||||229.42|158.3|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|229.42||||229.42|0|174.36|25.45
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]|TML WC [212537]|229.42||||229.42|114.71|174.36|25.45
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AARP [1000]|AARP [100000]|146.52||||146.52|73.26|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AETNA [1015]|AETNA [101529]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMBETTER [2930]|AMBETTER [293000]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146.52||||146.52|2.09|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146.52||||146.52|57.03|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|105.49|111.36|2.09
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]|146.52||||146.52|73.26|111.36|2.09
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]|146.52||||146.52|73.26|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146.52||||146.52|111.36|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146.52||||146.52|101.1|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA [1260]|CIGNA PPO [126025]|146.52||||146.52|58.61|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146.52||||146.52|73.26|111.36|2.09
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]|146.52||||146.52|101.1|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146.52||||146.52|2.09|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146.52||||146.52|101.1|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|146.52||||146.52|101.1|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|Self-pay|Self-pay|146.52||||146.52|29.3|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|TML [1980]|TML [198000]|146.52||||146.52|101.1|111.36|2.09
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]|146.52||||146.52|57.03|111.36|2.09
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]|146.52||||146.52|73.26|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNICARE [2040]|UNICARE [204000]|146.52||||146.52|73.26|111.36|2.09
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]|146.52||||146.52|73.26|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WEB TPA [2115]|WEB TPA [211500]|146.52||||146.52|101.1|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
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]|146.52||||146.52|0|111.36|2.09
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WORKER'S COMP [2125]|TML WC [212537]|146.52||||146.52|73.26|111.36|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AARP [1000]|AARP [100000]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AETNA [1015]|AETNA [101529]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMBETTER [2930]|AMBETTER [293000]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|136.66||||136.66|2.09|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.66||||136.66|98.4|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|136.66||||136.66|103.86|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|CIGNA [1260]|CIGNA PPO [126025]|136.66||||136.66|54.66|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|GROUP PENSION ADMIN [1450]|GPA [145000]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|136.66||||136.66|2.09|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|PHCS [1780]|PHCS MULTIPLAN [178000]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|Self-pay|Self-pay|136.66||||136.66|27.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|TML [1980]|TML [198000]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.66||||136.66|53.19|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UNICARE [2040]|UNICARE [204000]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.66||||136.66|68.33|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WEB TPA [2115]|WEB TPA [211500]|136.66||||136.66|94.3|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.66||||136.66|0|103.86|2.09
18303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION|3.375 g|WORKER'S COMP [2125]|TML WC [212537]|136.66||||136.66|68.33|103.86|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AARP [1000]|AARP [100000]|91.1||||91.1|45.55|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AETNA [1015]|AETNA [101529]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMBETTER [2930]|AMBETTER [293000]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|91.1||||91.1|2.09|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|91.1||||91.1|35.46|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|65.59|69.24|2.09
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]|91.1||||91.1|45.55|69.24|2.09
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]|91.1||||91.1|45.55|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|91.1||||91.1|69.24|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|91.1||||91.1|62.86|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA [1260]|CIGNA PPO [126025]|91.1||||91.1|36.44|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|91.1||||91.1|45.55|69.24|2.09
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]|91.1||||91.1|62.86|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|91.1||||91.1|2.09|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|91.1||||91.1|62.86|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|PHCS [1780]|PHCS MULTIPLAN [178000]|91.1||||91.1|62.86|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|Self-pay|Self-pay|91.1||||91.1|18.22|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|TML [1980]|TML [198000]|91.1||||91.1|62.86|69.24|2.09
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]|91.1||||91.1|35.46|69.24|2.09
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]|91.1||||91.1|45.55|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNICARE [2040]|UNICARE [204000]|91.1||||91.1|45.55|69.24|2.09
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]|91.1||||91.1|45.55|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WEB TPA [2115]|WEB TPA [211500]|91.1||||91.1|62.86|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
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]|91.1||||91.1|0|69.24|2.09
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WORKER'S COMP [2125]|TML WC [212537]|91.1||||91.1|45.55|69.24|2.09
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.51||||2.51||1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.51||||2.51|1.26|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.51||||2.51|1.81|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.51||||2.51|1.26|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.51||||2.51|1.26|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.51||||2.51|1.91|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.51||||2.51|1|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.51||||2.51||1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.51||||2.51|1.26|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.51||||2.51|0.5|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.51||||2.51|0.98|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.51||||2.51||1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.51||||2.51||1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.51||||2.51||1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.51||||2.51|1.73|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.51||||2.51|0|1.91|0.5
18307|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 400 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.51||||2.51||1.91|0.5
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|64.68||||64.68||49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64.68||||64.68|32.34|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64.68||||64.68|25.17|49.16|12.94
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]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.68||||64.68|46.57|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.68||||64.68|32.34|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.68||||64.68|32.34|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64.68||||64.68|49.16|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64.68||||64.68|44.63|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|64.68||||64.68|25.87|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64.68||||64.68||49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|64.68||||64.68|44.63|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64.68||||64.68|32.34|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64.68||||64.68|44.63|49.16|12.94
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]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.68||||64.68|0|49.16|12.94
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]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|64.68||||64.68|44.63|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|64.68||||64.68|12.94|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|64.68||||64.68|44.63|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.68||||64.68|25.17|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.68||||64.68||49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|64.68||||64.68||49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.68||||64.68||49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|64.68||||64.68|44.63|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.68||||64.68|0|49.16|12.94
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]|64.68||||64.68|0|49.16|12.94
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|64.68||||64.68||49.16|12.94
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AARP [1000]|AARP [100000]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AETNA [1015]|AETNA [101529]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|491.7||||491.7|9.35|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|491.7||||491.7|354.02|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|491.7||||491.7|373.69|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|CIGNA [1260]|CIGNA PPO [126025]|491.7||||491.7|196.68|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|491.7||||491.7|9.35|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|Self-pay|Self-pay|491.7||||491.7|98.34|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|TML [1980]|TML [198000]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|491.7||||491.7|191.37|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UNICARE [2040]|UNICARE [204000]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|491.7||||491.7|245.85|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|491.7||||491.7|339.27|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|491.7||||491.7|0|373.69|9.35
18315|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV|250 mL|WORKER'S COMP [2125]|TML WC [212537]|491.7||||491.7|245.85|373.69|9.35
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]|5.94||||5.94||4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|4.28|4.51|1.19
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]|5.94||||5.94|2.97|4.51|1.19
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]|5.94||||5.94|2.97|4.51|1.19
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 TRADITIONAL OF TEXAS [115503]|5.94||||5.94|4.51|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94||4.51|1.19
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]|5.94||||5.94|4.1|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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|5.94||||5.94|1.19|4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94||4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|5.94||||5.94||4.51|1.19
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]|5.94||||5.94||4.51|1.19
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
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]|TML WC [212537]|5.94||||5.94||4.51|1.19
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.72||||1.72||1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.72||||1.72|0.86|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.72||||1.72|0.67|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|1.24|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.72||||1.72|0.86|1.31|0.34
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]|1.72||||1.72|0.86|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.72||||1.72|1.31|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.72||||1.72|1.19|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.72||||1.72|0.69|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.72||||1.72||1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.72||||1.72|1.19|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.72||||1.72|0.86|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.72||||1.72|1.19|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.72||||1.72|1.19|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|Self-pay|Self-pay|1.72||||1.72|0.34|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.72||||1.72|1.19|1.31|0.34
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]|1.72||||1.72|0.67|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.72||||1.72||1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.72||||1.72||1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.72||||1.72||1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.72||||1.72|1.19|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.72||||1.72|0|1.31|0.34
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]|1.72||||1.72|0|1.31|0.34
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.72||||1.72||1.31|0.34
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AARP [1000]|AARP [100000]|141.24||||141.24||107.34|28.25
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]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AETNA [1015]|AETNA [101529]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141.24||||141.24|54.97|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|141.24||||141.24|70.62|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|141.24||||141.24|54.97|107.34|28.25
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]|141.24||||141.24|0|107.34|28.25
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]|141.24||||141.24|101.69|107.34|28.25
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]|141.24||||141.24|70.62|107.34|28.25
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]|141.24||||141.24|70.62|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|141.24||||141.24|107.34|107.34|28.25
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]|141.24||||141.24|54.97|107.34|28.25
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]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|141.24||||141.24|97.46|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|141.24||||141.24|56.5|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|141.24||||141.24||107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|141.24||||141.24|97.46|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|141.24||||141.24|70.62|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|141.24||||141.24|97.46|107.34|28.25
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]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141.24||||141.24|54.97|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141.24||||141.24|0|107.34|28.25
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]|141.24||||141.24|54.97|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|141.24||||141.24|97.46|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141.24||||141.24|54.97|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|Self-pay|Self-pay|141.24||||141.24|28.25|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|TML [1980]|TML [198000]|141.24||||141.24|97.46|107.34|28.25
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]|141.24||||141.24|54.97|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141.24||||141.24||107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNICARE [2040]|UNICARE [204000]|141.24||||141.24||107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141.24||||141.24||107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|141.24||||141.24|97.46|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141.24||||141.24|0|107.34|28.25
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]|141.24||||141.24|0|107.34|28.25
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|141.24||||141.24||107.34|28.25
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.21||||2.21||1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.21||||2.21|1.11|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.21||||2.21|0.86|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.21||||2.21|1.59|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.21||||2.21|1.11|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.21||||2.21|1.11|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.21||||2.21|1.68|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.21||||2.21|1.52|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.21||||2.21|0.88|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.21||||2.21||1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.21||||2.21|1.52|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.21||||2.21|1.11|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.21||||2.21|1.52|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.21||||2.21|0|1.68|0.44
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]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.21||||2.21|1.52|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.21||||2.21|0.44|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.21||||2.21|1.52|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.21||||2.21|0.86|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.21||||2.21||1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.21||||2.21||1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.21||||2.21||1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.21||||2.21|1.52|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.21||||2.21|0|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.21||||2.21||1.68|0.44
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|264||||264||200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|132|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|190.08|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|132|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|200.64|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264||200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|132|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|264||||264|52.8|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|102.75|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|264||||264||200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264|0|200.64|52.8
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]|264||||264|0|200.64|52.8
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|264||||264||200.64|52.8
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.61||||7.61||5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.61||||7.61|3.81|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.61||||7.61|2.96|5.78|1.52
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]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.61||||7.61|5.48|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.61||||7.61|3.81|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.61||||7.61|3.81|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.61||||7.61|5.78|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.61||||7.61|5.25|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.61||||7.61|3.04|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.61||||7.61||5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.61||||7.61|5.25|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.61||||7.61|3.81|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.61||||7.61|5.25|5.78|1.52
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]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.61||||7.61|0|5.78|1.52
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]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.61||||7.61|5.25|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|7.61||||7.61|1.52|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.61||||7.61|5.25|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.61||||7.61|2.96|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.61||||7.61||5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.61||||7.61||5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.61||||7.61||5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.61||||7.61|5.25|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.61||||7.61|0|5.78|1.52
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]|7.61||||7.61|0|5.78|1.52
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.61||||7.61||5.78|1.52
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89||0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.89||||0.89|0.45|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.89||||0.89|0.35|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.64|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.45|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.89||||0.89|0.68|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.89||||0.89|0.61|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.89||||0.89|0.36|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.89||||0.89||0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.89||||0.89|0.45|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.89||||0.89|0.61|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0|0.68|0.18
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]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.18|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.89||||0.89|0.61|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.35|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.89||||0.89||0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.89||||0.89|0.61|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89|0|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.89||||0.89||0.68|0.18
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.06||||1.06||0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.06||||1.06|0.53|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.06||||1.06|0.41|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0.76|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.53|0.81|0.21
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]|1.06||||1.06|0.53|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.06||||1.06|0.81|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.06||||1.06|0.73|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.06||||1.06|0.42|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.06||||1.06||0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.06||||1.06|0.53|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.06||||1.06|0.73|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.06||||1.06|0.21|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.06||||1.06|0.73|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06||0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.06||||1.06||0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06||0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.06||||1.06|0.73|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.06||||1.06||0.81|0.21
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.89||||4.89||3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.89||||4.89|2.45|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.89||||4.89|1.9|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.89||||4.89|3.52|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.89||||4.89|2.45|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.89||||4.89|2.45|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.89||||4.89|3.72|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.89||||4.89|3.37|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.89||||4.89|1.96|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.89||||4.89||3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.89||||4.89|3.37|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.89||||4.89|2.45|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.89||||4.89|3.37|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.89||||4.89|0|3.72|0.98
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]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.89||||4.89|3.37|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|4.89||||4.89|0.98|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.89||||4.89|3.37|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.89||||4.89|1.9|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.89||||4.89||3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.89||||4.89||3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.89||||4.89||3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.89||||4.89|3.37|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.89||||4.89|0|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.89||||4.89||3.72|0.98
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.94||||5.94||4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.94||||5.94|2.97|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.94||||5.94|2.31|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|4.28|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.97|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|2.97|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.94||||5.94|4.51|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.94||||5.94|4.1|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.94||||5.94|2.38|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.94||||5.94||4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.94||||5.94|2.97|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.94||||5.94|4.1|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|Self-pay|Self-pay|5.94||||5.94|1.19|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.94||||5.94|4.1|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|2.31|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94||4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.94||||5.94||4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94||4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.94||||5.94|4.1|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94|0|4.51|1.19
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]|5.94||||5.94|0|4.51|1.19
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.94||||5.94||4.51|1.19
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AARP [1000]|AARP [100000]|79.42||||79.42||60.36|15.88
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]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AETNA [1015]|AETNA [101529]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AMBETTER [2930]|AMBETTER [293000]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.42||||79.42|30.91|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.42||||79.42|39.71|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.42||||79.42|30.91|60.36|15.88
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]|79.42||||79.42|0|60.36|15.88
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]|79.42||||79.42|57.18|60.36|15.88
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]|79.42||||79.42|39.71|60.36|15.88
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]|79.42||||79.42|39.71|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.42||||79.42|60.36|60.36|15.88
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]|79.42||||79.42|30.91|60.36|15.88
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]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.42||||79.42|54.8|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|CIGNA [1260]|CIGNA PPO [126025]|79.42||||79.42|31.77|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.42||||79.42||60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|GROUP PENSION ADMIN [1450]|GPA [145000]|79.42||||79.42|54.8|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.42||||79.42|39.71|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.42||||79.42|54.8|60.36|15.88
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]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.42||||79.42|30.91|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.42||||79.42|0|60.36|15.88
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]|79.42||||79.42|30.91|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|PHCS [1780]|PHCS MULTIPLAN [178000]|79.42||||79.42|54.8|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.42||||79.42|30.91|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|Self-pay|Self-pay|79.42||||79.42|15.88|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|TML [1980]|TML [198000]|79.42||||79.42|54.8|60.36|15.88
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]|79.42||||79.42|30.91|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.42||||79.42||60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UNICARE [2040]|UNICARE [204000]|79.42||||79.42||60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.42||||79.42||60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|WEB TPA [2115]|WEB TPA [211500]|79.42||||79.42|54.8|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.42||||79.42|0|60.36|15.88
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]|79.42||||79.42|0|60.36|15.88
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|WORKER'S COMP [2125]|TML WC [212537]|79.42||||79.42||60.36|15.88
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AARP [1000]|AARP [100000]|0.61||||0.61||0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.61||||0.61|0.31|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.61||||0.61|0.44|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.61||||0.61|0.31|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.61||||0.61|0.31|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.61||||0.61|0.46|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.61||||0.61||0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.61||||0.61|0.31|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|Self-pay|Self-pay|0.61||||0.61|0.12|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|TML [1980]|TML [198000]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.61||||0.61|0.24|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.61||||0.61||0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.61||||0.61||0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.61||||0.61||0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.61||||0.61|0.42|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.61||||0.61|0|0.46|0.12
19483|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.61||||0.61||0.46|0.12
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|528||||528||401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528||||528|264|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528||||528|380.16|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528||||528|264|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528||||528|264|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528||||528|401.28|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|528||||528|211.2|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528||||528||401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528||||528|264|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|Self-pay|Self-pay|528||||528|105.6|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|TML [1980]|TML [198000]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528||||528|205.5|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528||||528||401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|528||||528||401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528||||528||401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|528||||528|364.32|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528||||528|0|401.28|105.6
19636|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 10 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|528||||528||401.28|105.6
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|369.6||||369.6||280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|369.6||||369.6|184.8|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|369.6||||369.6|143.85|280.9|73.92
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]|369.6||||369.6|0|280.9|73.92
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]|369.6||||369.6|266.11|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|369.6||||369.6|184.8|280.9|73.92
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]|369.6||||369.6|184.8|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|369.6||||369.6|280.9|280.9|73.92
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]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|369.6||||369.6|255.02|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|369.6||||369.6|147.84|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|369.6||||369.6||280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|369.6||||369.6|255.02|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|369.6||||369.6|184.8|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|369.6||||369.6|255.02|280.9|73.92
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]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|369.6||||369.6|0|280.9|73.92
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]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|369.6||||369.6|255.02|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|369.6||||369.6|73.92|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|TML [1980]|TML [198000]|369.6||||369.6|255.02|280.9|73.92
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]|369.6||||369.6|143.85|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|369.6||||369.6||280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|369.6||||369.6||280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|369.6||||369.6||280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|369.6||||369.6|255.02|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|369.6||||369.6|0|280.9|73.92
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]|369.6||||369.6|0|280.9|73.92
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|369.6||||369.6||280.9|73.92
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AARP [1000]|AARP [100000]|594||||594||451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AETNA [1015]|AETNA [101529]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AMBETTER [2930]|AMBETTER [293000]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594||||594|297|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|427.68|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|297|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|297|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594||||594|451.44|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|594||||594|237.6|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594||||594||451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594||||594|297|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|Self-pay|Self-pay|594||||594|118.8|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|TML [1980]|TML [198000]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|231.18|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594||451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UNICARE [2040]|UNICARE [204000]|594||||594||451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594||451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WEB TPA [2115]|WEB TPA [211500]|594||||594|409.86|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594|0|451.44|118.8
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|594||||594||451.44|118.8
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AARP [1000]|AARP [100000]|1818.24||||1818.24||1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AETNA [1015]|AETNA [101529]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMBETTER [2930]|AMBETTER [293000]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1818.24||||1818.24|909.12|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1818.24||||1818.24|1309.13|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1818.24||||1818.24|909.12|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1818.24||||1818.24|909.12|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1818.24||||1818.24|1381.86|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|CIGNA [1260]|CIGNA PPO [126025]|1818.24||||1818.24|727.3|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1818.24||||1818.24||1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1818.24||||1818.24|909.12|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|Self-pay|Self-pay|1818.24||||1818.24|363.65|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|TML [1980]|TML [198000]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1818.24||||1818.24|707.66|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1818.24||||1818.24||1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UNICARE [2040]|UNICARE [204000]|1818.24||||1818.24||1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1818.24||||1818.24||1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WEB TPA [2115]|WEB TPA [211500]|1818.24||||1818.24|1254.59|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1818.24||||1818.24|0|1381.86|363.65
19741|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL GEL|45 g|WORKER'S COMP [2125]|TML WC [212537]|1818.24||||1818.24||1381.86|363.65
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|221.1||||221.1||168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|221.1||||221.1|110.55|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|221.1||||221.1|86.05|168.04|44.22
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]|221.1||||221.1|0|168.04|44.22
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]|221.1||||221.1|159.19|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221.1||||221.1|110.55|168.04|44.22
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]|221.1||||221.1|110.55|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|221.1||||221.1|168.04|168.04|44.22
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]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|221.1||||221.1|152.56|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|221.1||||221.1|88.44|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|221.1||||221.1||168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|221.1||||221.1|152.56|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|221.1||||221.1|110.55|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|221.1||||221.1|152.56|168.04|44.22
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]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221.1||||221.1|0|168.04|44.22
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]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|221.1||||221.1|152.56|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|221.1||||221.1|44.22|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|221.1||||221.1|152.56|168.04|44.22
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]|221.1||||221.1|86.05|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221.1||||221.1||168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|221.1||||221.1||168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221.1||||221.1||168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|221.1||||221.1|152.56|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221.1||||221.1|0|168.04|44.22
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]|221.1||||221.1|0|168.04|44.22
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|221.1||||221.1||168.04|44.22
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AARP [1000]|AARP [100000]|2014.85||||2014.85||1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AETNA [1015]|AETNA [101529]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AMBETTER [2930]|AMBETTER [293000]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2014.85||||2014.85|1007.43|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2014.85||||2014.85|1450.69|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2014.85||||2014.85|1007.43|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2014.85||||2014.85|1007.43|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2014.85||||2014.85|1531.29|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|CIGNA [1260]|CIGNA PPO [126025]|2014.85||||2014.85|805.94|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2014.85||||2014.85||1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|GROUP PENSION ADMIN [1450]|GPA [145000]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2014.85||||2014.85|1007.43|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|PHCS [1780]|PHCS MULTIPLAN [178000]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|Self-pay|Self-pay|2014.85||||2014.85|402.97|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|TML [1980]|TML [198000]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2014.85||||2014.85|784.18|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2014.85||||2014.85||1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|UNICARE [2040]|UNICARE [204000]|2014.85||||2014.85||1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2014.85||||2014.85||1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|WEB TPA [2115]|WEB TPA [211500]|2014.85||||2014.85|1390.25|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2014.85||||2014.85|0|1531.29|402.97
19805|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 0.75 % TOPICAL CREAM|45 g|WORKER'S COMP [2125]|TML WC [212537]|2014.85||||2014.85||1531.29|402.97
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]|9.23||||9.23||7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.23||||9.23|2.39|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|6.65|7.01|1.85
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]|9.23||||9.23|4.62|7.01|1.85
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]|9.23||||9.23|4.62|7.01|1.85
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 TRADITIONAL OF TEXAS [115503]|9.23||||9.23|7.01|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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 - GREAT WEST [126009]|9.23||||9.23|6.37|7.01|1.85
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 PPO [126025]|9.23||||9.23|3.69|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.23||||9.23||7.01|1.85
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]|9.23||||9.23|6.37|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.23||||9.23|2.39|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.23||||9.23|6.37|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23|6.37|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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|9.23||||9.23|1.85|7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|9.23||||9.23|6.37|7.01|1.85
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]|9.23||||9.23|3.59|7.01|1.85
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]|9.23||||9.23||7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|9.23||||9.23||7.01|1.85
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]|9.23||||9.23||7.01|1.85
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|9.23||||9.23|6.37|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|9.23||||9.23|0|7.01|1.85
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]|TML WC [212537]|9.23||||9.23||7.01|1.85
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.54||||2.54||1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.54||||2.54|0.99|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.54||||2.54|1.27|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.54||||2.54|0.99|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
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]|2.54||||2.54|1.83|1.93|0.51
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]|2.54||||2.54|1.27|1.93|0.51
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]|2.54||||2.54|1.27|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.54||||2.54|1.93|1.93|0.51
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]|2.54||||2.54|0.99|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.54||||2.54|1.75|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.54||||2.54|1.02|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.54||||2.54||1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.54||||2.54|1.75|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.54||||2.54|1.27|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.54||||2.54|1.75|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.54||||2.54|0|1.93|0.51
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]|2.54||||2.54|0.99|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.54||||2.54|0|1.93|0.51
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]|2.54||||2.54|0.99|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.54||||2.54|1.75|1.93|0.51
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]|2.54||||2.54|0.99|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|Self-pay|Self-pay|2.54||||2.54|0.51|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|TML [1980]|TML [198000]|2.54||||2.54|1.75|1.93|0.51
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]|2.54||||2.54|0.99|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.54||||2.54||1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.54||||2.54||1.93|0.51
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]|2.54||||2.54||1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.54||||2.54|1.75|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
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]|2.54||||2.54|0|1.93|0.51
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.54||||2.54||1.93|0.51
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AARP [1000]|AARP [100000]|363.66||||363.66||276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA [1015]|AETNA [101529]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMBETTER [2930]|AMBETTER [293000]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|363.66||||363.66|181.83|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|363.66||||363.66|141.54|276.38|72.73
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]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363.66||||363.66|261.84|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363.66||||363.66|181.83|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363.66||||363.66|181.83|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|363.66||||363.66|276.38|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|363.66||||363.66|250.93|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA PPO [126025]|363.66||||363.66|145.46|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|363.66||||363.66||276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|363.66||||363.66|250.93|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|363.66||||363.66|181.83|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|363.66||||363.66|250.93|276.38|72.73
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]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363.66||||363.66|0|276.38|72.73
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]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|363.66||||363.66|250.93|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|Self-pay|Self-pay|363.66||||363.66|72.73|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|TML [1980]|TML [198000]|363.66||||363.66|250.93|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363.66||||363.66|141.54|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363.66||||363.66||276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNICARE [2040]|UNICARE [204000]|363.66||||363.66||276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363.66||||363.66||276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WEB TPA [2115]|WEB TPA [211500]|363.66||||363.66|250.93|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363.66||||363.66|0|276.38|72.73
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]|363.66||||363.66|0|276.38|72.73
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TML WC [212537]|363.66||||363.66||276.38|72.73
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.19||||1.19||0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.19||||1.19|0.6|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.19||||1.19|0.46|0.9|0.24
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]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.19||||1.19|0.86|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.19||||1.19|0.6|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.19||||1.19|0.6|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.19||||1.19|0.9|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.19||||1.19|0.82|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.19||||1.19|0.48|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.19||||1.19||0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.19||||1.19|0.82|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.19||||1.19|0.6|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.19||||1.19|0.82|0.9|0.24
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]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.19||||1.19|0|0.9|0.24
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]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.19||||1.19|0.82|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|1.19||||1.19|0.24|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.19||||1.19|0.82|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.19||||1.19|0.46|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.19||||1.19||0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.19||||1.19||0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.19||||1.19||0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.19||||1.19|0.82|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.19||||1.19|0|0.9|0.24
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]|1.19||||1.19|0|0.9|0.24
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.19||||1.19||0.9|0.24
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|73.79||||73.79||56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|73.79||||73.79|36.9|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|73.79||||73.79|53.13|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|73.79||||73.79|36.9|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|73.79||||73.79|36.9|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|73.79||||73.79|56.08|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|73.79||||73.79|29.52|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|73.79||||73.79||56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|73.79||||73.79|36.9|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|73.79||||73.79|14.76|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|73.79||||73.79|28.72|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|73.79||||73.79||56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|73.79||||73.79||56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|73.79||||73.79||56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|73.79||||73.79|50.92|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|73.79||||73.79|0|56.08|14.76
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|73.79||||73.79||56.08|14.76
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|32.61||||32.61||24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.61||||32.61|12.69|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|32.61||||32.61|16.31|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|32.61||||32.61|12.69|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
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]|32.61||||32.61|23.48|24.78|6.52
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]|32.61||||32.61|16.31|24.78|6.52
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]|32.61||||32.61|16.31|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|32.61||||32.61|24.78|24.78|6.52
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]|32.61||||32.61|12.69|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|32.61||||32.61|22.5|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|32.61||||32.61|13.04|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|32.61||||32.61||24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32.61||||32.61|22.5|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|32.61||||32.61|16.31|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32.61||||32.61|22.5|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.61||||32.61|0|24.78|6.52
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]|32.61||||32.61|12.69|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.61||||32.61|0|24.78|6.52
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]|32.61||||32.61|12.69|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32.61||||32.61|22.5|24.78|6.52
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]|32.61||||32.61|12.69|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|32.61||||32.61|6.52|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|32.61||||32.61|22.5|24.78|6.52
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]|32.61||||32.61|12.69|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.61||||32.61||24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|32.61||||32.61||24.78|6.52
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]|32.61||||32.61||24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|32.61||||32.61|22.5|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
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]|32.61||||32.61|0|24.78|6.52
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|32.61||||32.61||24.78|6.52
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|44.88||||44.88||34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.88||||44.88|22.44|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.88||||44.88|17.47|34.11|8.98
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]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.88||||44.88|32.31|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.88||||44.88|22.44|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.88||||44.88|22.44|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.88||||44.88|34.11|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.88||||44.88|30.97|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|44.88||||44.88|17.95|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.88||||44.88||34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|44.88||||44.88|30.97|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.88||||44.88|22.44|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.88||||44.88|30.97|34.11|8.98
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]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.88||||44.88|0|34.11|8.98
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]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|44.88||||44.88|30.97|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|44.88||||44.88|8.98|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|44.88||||44.88|30.97|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.88||||44.88|17.47|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.88||||44.88||34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|44.88||||44.88||34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.88||||44.88||34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|44.88||||44.88|30.97|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.88||||44.88|0|34.11|8.98
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]|44.88||||44.88|0|34.11|8.98
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|44.88||||44.88||34.11|8.98
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|115.2||||115.2||87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|115.2||||115.2|57.6|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|115.2||||115.2|44.84|87.55|23.04
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]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|115.2||||115.2|82.94|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115.2||||115.2|57.6|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|115.2||||115.2|57.6|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|115.2||||115.2|87.55|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|115.2||||115.2|79.49|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|115.2||||115.2|46.08|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|115.2||||115.2||87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|115.2||||115.2|79.49|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|115.2||||115.2|57.6|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|115.2||||115.2|79.49|87.55|23.04
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]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115.2||||115.2|0|87.55|23.04
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]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|115.2||||115.2|79.49|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|Self-pay|Self-pay|115.2||||115.2|23.04|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|115.2||||115.2|79.49|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|115.2||||115.2|44.84|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115.2||||115.2||87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|115.2||||115.2||87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115.2||||115.2||87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|115.2||||115.2|79.49|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115.2||||115.2|0|87.55|23.04
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]|115.2||||115.2|0|87.55|23.04
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|115.2||||115.2||87.55|23.04
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.81||||0.81||0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.81||||0.81|0.41|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.81||||0.81|0.32|0.62|0.16
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]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.81||||0.81|0.58|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.81||||0.81|0.41|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.81||||0.81|0.41|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.81||||0.81|0.62|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.81||||0.81|0.56|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.81||||0.81||0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.81||||0.81|0.56|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.81||||0.81|0.41|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.81||||0.81|0.56|0.62|0.16
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]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.81||||0.81|0|0.62|0.16
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]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.81||||0.81|0.56|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.81||||0.81|0.16|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.81||||0.81|0.56|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.81||||0.81|0.32|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.81||||0.81||0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.81||||0.81||0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.81||||0.81||0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.81||||0.81|0.56|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.81||||0.81|0|0.62|0.16
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]|0.81||||0.81|0|0.62|0.16
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.81||||0.81||0.62|0.16
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|62.04||||62.04||47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62.04||||62.04|4.29|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62.04||||62.04|24.15|47.15|4.29
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]|62.04||||62.04|0|47.15|4.29
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]|62.04||||62.04|44.67|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.04||||62.04|31.02|47.15|4.29
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]|62.04||||62.04|31.02|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62.04||||62.04|47.15|47.15|4.29
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]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62.04||||62.04|42.81|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|62.04||||62.04|24.82|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62.04||||62.04||47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|62.04||||62.04|42.81|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62.04||||62.04|4.29|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62.04||||62.04|42.81|47.15|4.29
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]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.04||||62.04|0|47.15|4.29
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]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|62.04||||62.04|42.81|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|62.04||||62.04|12.41|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|62.04||||62.04|42.81|47.15|4.29
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]|62.04||||62.04|24.15|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.04||||62.04||47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|62.04||||62.04||47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.04||||62.04||47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|62.04||||62.04|42.81|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.04||||62.04|0|47.15|4.29
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]|62.04||||62.04|0|47.15|4.29
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|62.04||||62.04||47.15|4.29
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AARP [1000]|AARP [100000]|124.88||||124.88||94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AETNA [1015]|AETNA [101529]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMBETTER [2930]|AMBETTER [293000]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124.88||||124.88|48.6|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|124.88||||124.88|62.44|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|124.88||||124.88|48.6|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
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]|124.88||||124.88|89.91|94.91|24.98
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]|124.88||||124.88|62.44|94.91|24.98
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]|124.88||||124.88|62.44|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|124.88||||124.88|94.91|94.91|24.98
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]|124.88||||124.88|48.6|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|124.88||||124.88|86.17|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA [1260]|CIGNA PPO [126025]|124.88||||124.88|49.95|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|124.88||||124.88||94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|124.88||||124.88|86.17|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|124.88||||124.88|62.44|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|124.88||||124.88|86.17|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124.88||||124.88|0|94.91|24.98
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]|124.88||||124.88|48.6|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124.88||||124.88|0|94.91|24.98
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]|124.88||||124.88|48.6|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|124.88||||124.88|86.17|94.91|24.98
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]|124.88||||124.88|48.6|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|Self-pay|Self-pay|124.88||||124.88|24.98|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|TML [1980]|TML [198000]|124.88||||124.88|86.17|94.91|24.98
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]|124.88||||124.88|48.6|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124.88||||124.88||94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNICARE [2040]|UNICARE [204000]|124.88||||124.88||94.91|24.98
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]|124.88||||124.88||94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WEB TPA [2115]|WEB TPA [211500]|124.88||||124.88|86.17|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
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]|124.88||||124.88|0|94.91|24.98
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WORKER'S COMP [2125]|TML WC [212537]|124.88||||124.88||94.91|24.98
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AARP [1000]|AARP [100000]|1625.32||||1625.32||1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AETNA [1015]|AETNA [101529]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMBETTER [2930]|AMBETTER [293000]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1625.32||||1625.32|812.66|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1625.32||||1625.32|1170.23|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1625.32||||1625.32|812.66|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1625.32||||1625.32|812.66|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1625.32||||1625.32|1235.24|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|CIGNA [1260]|CIGNA PPO [126025]|1625.32||||1625.32|650.13|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1625.32||||1625.32||1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1625.32||||1625.32|812.66|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|Self-pay|Self-pay|1625.32||||1625.32|325.06|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|TML [1980]|TML [198000]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1625.32||||1625.32|632.57|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1625.32||||1625.32||1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UNICARE [2040]|UNICARE [204000]|1625.32||||1625.32||1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1625.32||||1625.32||1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WEB TPA [2115]|WEB TPA [211500]|1625.32||||1625.32|1121.47|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1625.32||||1625.32|0|1235.24|325.06
21135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)|5 mL|WORKER'S COMP [2125]|TML WC [212537]|1625.32||||1625.32||1235.24|325.06
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|97.3||||97.3||73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.3||||97.3|48.65|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.3||||97.3|37.87|73.95|19.46
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]|97.3||||97.3|0|73.95|19.46
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]|97.3||||97.3|70.06|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.3||||97.3|48.65|73.95|19.46
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]|97.3||||97.3|48.65|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97.3||||97.3|73.95|73.95|19.46
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]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97.3||||97.3|67.14|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|97.3||||97.3|38.92|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.3||||97.3||73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|97.3||||97.3|67.14|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.3||||97.3|48.65|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.3||||97.3|67.14|73.95|19.46
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]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.3||||97.3|0|73.95|19.46
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]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|97.3||||97.3|67.14|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|97.3||||97.3|19.46|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|97.3||||97.3|67.14|73.95|19.46
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]|97.3||||97.3|37.87|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.3||||97.3||73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|97.3||||97.3||73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.3||||97.3||73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|97.3||||97.3|67.14|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.3||||97.3|0|73.95|19.46
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]|97.3||||97.3|0|73.95|19.46
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|97.3||||97.3||73.95|19.46
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|14.52||||14.52||11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.52||||14.52|0.62|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.52||||14.52|5.65|11.04|0.62
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]|14.52||||14.52|0|11.04|0.62
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]|14.52||||14.52|10.45|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.52||||14.52|7.26|11.04|0.62
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]|14.52||||14.52|7.26|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.52||||14.52|11.04|11.04|0.62
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]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.52||||14.52|10.02|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|14.52||||14.52|5.81|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.52||||14.52||11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.52||||14.52|10.02|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.52||||14.52|0.62|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.52||||14.52|10.02|11.04|0.62
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]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.52||||14.52|0|11.04|0.62
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]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.52||||14.52|10.02|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|Self-pay|Self-pay|14.52||||14.52|2.9|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|14.52||||14.52|10.02|11.04|0.62
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]|14.52||||14.52|5.65|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.52||||14.52||11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|14.52||||14.52||11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.52||||14.52||11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|14.52||||14.52|10.02|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.52||||14.52|0|11.04|0.62
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]|14.52||||14.52|0|11.04|0.62
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|14.52||||14.52||11.04|0.62
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|308.92||||308.92||234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|308.92||||308.92|154.46|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|308.92||||308.92|120.23|234.78|61.78
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]|308.92||||308.92|0|234.78|61.78
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]|308.92||||308.92|222.42|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|308.92||||308.92|154.46|234.78|61.78
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]|308.92||||308.92|154.46|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|308.92||||308.92|234.78|234.78|61.78
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]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|308.92||||308.92|213.15|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|308.92||||308.92|123.57|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|308.92||||308.92||234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|308.92||||308.92|213.15|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|308.92||||308.92|154.46|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|308.92||||308.92|213.15|234.78|61.78
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]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|308.92||||308.92|0|234.78|61.78
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]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|308.92||||308.92|213.15|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|308.92||||308.92|61.78|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|308.92||||308.92|213.15|234.78|61.78
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]|308.92||||308.92|120.23|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|308.92||||308.92||234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|308.92||||308.92||234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|308.92||||308.92||234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|308.92||||308.92|213.15|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|308.92||||308.92|0|234.78|61.78
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]|308.92||||308.92|0|234.78|61.78
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|308.92||||308.92||234.78|61.78
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.66||||6.66||5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.66||||6.66|3.33|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.66||||6.66|2.59|5.06|1.33
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]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.66||||6.66|4.8|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.66||||6.66|3.33|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.66||||6.66|3.33|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.66||||6.66|5.06|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.66||||6.66|4.6|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.66||||6.66|2.66|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.66||||6.66||5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.66||||6.66|4.6|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.66||||6.66|3.33|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.66||||6.66|4.6|5.06|1.33
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]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.66||||6.66|0|5.06|1.33
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]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.66||||6.66|4.6|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|6.66||||6.66|1.33|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.66||||6.66|4.6|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.66||||6.66|2.59|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.66||||6.66||5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.66||||6.66||5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.66||||6.66||5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.66||||6.66|4.6|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.66||||6.66|0|5.06|1.33
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]|6.66||||6.66|0|5.06|1.33
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.66||||6.66||5.06|1.33
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|217.61||||217.61||165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|217.61||||217.61|108.81|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.61||||217.61|156.68|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.61||||217.61|108.81|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.61||||217.61|108.81|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|217.61||||217.61|165.38|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|217.61||||217.61|87.04|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|217.61||||217.61||165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|217.61||||217.61|108.81|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|Self-pay|Self-pay|217.61||||217.61|43.52|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|TML [1980]|TML [198000]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.61||||217.61|84.69|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.61||||217.61||165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|217.61||||217.61||165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.61||||217.61||165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|217.61||||217.61|150.15|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.61||||217.61|0|165.38|43.52
21880|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|217.61||||217.61||165.38|43.52
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AARP [1000]|AARP [100000]|3528.23||||3528.23||2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AETNA [1015]|AETNA [101529]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMBETTER [2930]|AMBETTER [293000]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3528.23||||3528.23|1373.19|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3528.23||||3528.23|35.41|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3528.23||||3528.23|1373.19|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
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]|3528.23||||3528.23|2540.33|2681.45|35.41
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]|3528.23||||3528.23|1764.12|2681.45|35.41
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]|3528.23||||3528.23|1764.12|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3528.23||||3528.23|2681.45|2681.45|35.41
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]|3528.23||||3528.23|1373.19|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3528.23||||3528.23|2434.48|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|3528.23||||3528.23|1411.29|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3528.23||||3528.23||2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3528.23||||3528.23|2434.48|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3528.23||||3528.23|35.41|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3528.23||||3528.23|2434.48|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3528.23||||3528.23|0|2681.45|35.41
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]|3528.23||||3528.23|1373.19|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3528.23||||3528.23|0|2681.45|35.41
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]|3528.23||||3528.23|1373.19|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3528.23||||3528.23|2434.48|2681.45|35.41
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]|3528.23||||3528.23|1373.19|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|Self-pay|Self-pay|3528.23||||3528.23|705.65|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|TML [1980]|TML [198000]|3528.23||||3528.23|2434.48|2681.45|35.41
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]|3528.23||||3528.23|1373.19|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3528.23||||3528.23||2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNICARE [2040]|UNICARE [204000]|3528.23||||3528.23||2681.45|35.41
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]|3528.23||||3528.23||2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WEB TPA [2115]|WEB TPA [211500]|3528.23||||3528.23|2434.48|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
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]|3528.23||||3528.23|0|2681.45|35.41
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|3528.23||||3528.23||2681.45|35.41
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.21||||2.21||1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.21||||2.21|1.11|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.21||||2.21|0.86|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.21||||2.21|1.59|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.21||||2.21|1.11|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.21||||2.21|1.11|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.21||||2.21|1.68|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.21||||2.21|1.52|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.21||||2.21|0.88|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.21||||2.21||1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.21||||2.21|1.52|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.21||||2.21|1.11|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.21||||2.21|1.52|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.21||||2.21|0|1.68|0.44
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]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.21||||2.21|1.52|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|Self-pay|Self-pay|2.21||||2.21|0.44|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.21||||2.21|1.52|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.21||||2.21|0.86|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.21||||2.21||1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.21||||2.21||1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.21||||2.21||1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.21||||2.21|1.52|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.21||||2.21|0|1.68|0.44
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]|2.21||||2.21|0|1.68|0.44
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.21||||2.21||1.68|0.44
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AARP [1000]|AARP [100000]|22857.26||||22857.26||17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AETNA [1015]|AETNA [101529]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AMBETTER [2930]|AMBETTER [293000]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22857.26||||22857.26|9.61|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22857.26||||22857.26|16457.23|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22857.26||||22857.26|11428.63|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22857.26||||22857.26|11428.63|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22857.26||||22857.26|17371.52|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|CIGNA [1260]|CIGNA PPO [126025]|22857.26||||22857.26|11428.63|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22857.26||||22857.26||17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22857.26||||22857.26|9.61|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|Self-pay|Self-pay|22857.26||||22857.26|4571.45|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|TML [1980]|TML [198000]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22857.26||||22857.26|8896.05|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22857.26||||22857.26||17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|UNICARE [2040]|UNICARE [204000]|22857.26||||22857.26||17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22857.26||||22857.26||17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|WEB TPA [2115]|WEB TPA [211500]|22857.26||||22857.26|15771.51|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22857.26||||22857.26|0|17371.52|9.61
22185|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION|1.5 mL|WORKER'S COMP [2125]|TML WC [212537]|22857.26||||22857.26||17371.52|9.61
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AARP [1000]|AARP [100000]|223.94||||223.94||170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AETNA [1015]|AETNA [101529]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|223.94||||223.94|111.97|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223.94||||223.94|161.24|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223.94||||223.94|111.97|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223.94||||223.94|111.97|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|223.94||||223.94|170.19|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|223.94||||223.94|89.58|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|223.94||||223.94||170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|223.94||||223.94|111.97|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|Self-pay|Self-pay|223.94||||223.94|44.79|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|TML [1980]|TML [198000]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223.94||||223.94|87.16|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223.94||||223.94||170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|223.94||||223.94||170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223.94||||223.94||170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|223.94||||223.94|154.52|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223.94||||223.94|0|170.19|44.79
22240|ERX|0250 - PHARMACY-GENERAL|TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE NEBULIZATION REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|223.94||||223.94||170.19|44.79
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|50.64||||50.64||38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.64||||50.64|25.32|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50.64||||50.64|19.71|38.49|10.13
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]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.64||||50.64|36.46|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.64||||50.64|25.32|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.64||||50.64|25.32|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50.64||||50.64|38.49|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50.64||||50.64|34.94|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|50.64||||50.64|20.26|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.64||||50.64||38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|50.64||||50.64|34.94|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.64||||50.64|25.32|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.64||||50.64|34.94|38.49|10.13
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]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.64||||50.64|0|38.49|10.13
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]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|50.64||||50.64|34.94|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|50.64||||50.64|10.13|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|50.64||||50.64|34.94|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.64||||50.64|19.71|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.64||||50.64||38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|50.64||||50.64||38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.64||||50.64||38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|50.64||||50.64|34.94|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.64||||50.64|0|38.49|10.13
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]|50.64||||50.64|0|38.49|10.13
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|50.64||||50.64||38.49|10.13
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|327.89||||327.89||249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AMBETTER [2930]|AMBETTER [293000]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|327.89||||327.89|163.95|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327.89||||327.89|236.08|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327.89||||327.89|163.95|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327.89||||327.89|163.95|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|327.89||||327.89|249.2|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|327.89||||327.89|131.16|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|327.89||||327.89||249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|327.89||||327.89|163.95|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|327.89||||327.89|65.58|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|TML [1980]|TML [198000]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327.89||||327.89|127.61|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327.89||||327.89||249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|UNICARE [2040]|UNICARE [204000]|327.89||||327.89||249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327.89||||327.89||249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|WEB TPA [2115]|WEB TPA [211500]|327.89||||327.89|226.24|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327.89||||327.89|0|249.2|65.58
22290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 125 MG/5 ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|327.89||||327.89||249.2|65.58
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|13.86||||13.86|6.93|10.53|0.51
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]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.86||||13.86|5.39|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.86||||13.86|0.51|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.86||||13.86|5.39|10.53|0.51
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]|13.86||||13.86|0|10.53|0.51
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]|13.86||||13.86|9.98|10.53|0.51
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]|13.86||||13.86|6.93|10.53|0.51
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]|13.86||||13.86|6.93|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.86||||13.86|10.53|10.53|0.51
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]|13.86||||13.86|5.39|10.53|0.51
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]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.86||||13.86|9.56|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|13.86||||13.86|5.54|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.86||||13.86|6.93|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.86||||13.86|9.56|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.86||||13.86|0.51|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.86||||13.86|9.56|10.53|0.51
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]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.86||||13.86|5.39|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.86||||13.86|0|10.53|0.51
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]|13.86||||13.86|5.39|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.86||||13.86|9.56|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.86||||13.86|5.39|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|13.86||||13.86|2.77|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|13.86||||13.86|9.56|10.53|0.51
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]|13.86||||13.86|5.39|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.86||||13.86|6.93|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|13.86||||13.86|6.93|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.86||||13.86|6.93|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|13.86||||13.86|9.56|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.86||||13.86|0|10.53|0.51
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]|13.86||||13.86|0|10.53|0.51
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|13.86||||13.86|6.93|10.53|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|33||||33|16.5|25.08|0.51
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]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|25.08|0.51
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]|33||||33|12.84|25.08|0.51
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]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|0.51|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|25.08|0.51
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]|33||||33|0|25.08|0.51
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]|33||||33|23.76|25.08|0.51
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]|33||||33|16.5|25.08|0.51
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]|33||||33|16.5|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|25.08|0.51
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]|33||||33|12.84|25.08|0.51
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]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|16.5|25.08|0.51
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]|33||||33|22.77|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|0.51|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|25.08|0.51
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]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|25.08|0.51
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]|33||||33|12.84|25.08|0.51
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]|33||||33|0|25.08|0.51
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]|33||||33|0|25.08|0.51
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]|33||||33|12.84|25.08|0.51
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]|33||||33|22.77|25.08|0.51
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]|33||||33|12.84|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|33||||33|6.6|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|33||||33|22.77|25.08|0.51
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]|33||||33|12.84|25.08|0.51
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]|33||||33|16.5|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|33||||33|16.5|25.08|0.51
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]|33||||33|16.5|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|25.08|0.51
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]|33||||33|0|25.08|0.51
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]|33||||33|0|25.08|0.51
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|33||||33|16.5|25.08|0.51
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.71||||18.71||14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.71||||18.71|9.36|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.71||||18.71|13.47|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.71||||18.71|9.36|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.71||||18.71|9.36|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.71||||18.71|14.22|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.71||||18.71|7.48|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.71||||18.71||14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.71||||18.71|9.36|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|Self-pay|Self-pay|18.71||||18.71|3.74|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.71||||18.71|7.28|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.71||||18.71||14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.71||||18.71||14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.71||||18.71||14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.71||||18.71|12.91|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.71||||18.71|0|14.22|3.74
22660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.71||||18.71||14.22|3.74
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|2820.98||||2820.98||2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2820.98||||2820.98|1097.93|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2820.98||||2820.98|1410.49|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2820.98||||2820.98|1097.93|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
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]|2820.98||||2820.98|2031.11|2143.94|564.2
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]|2820.98||||2820.98|1410.49|2143.94|564.2
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]|2820.98||||2820.98|1410.49|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2820.98||||2820.98|2143.94|2143.94|564.2
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]|2820.98||||2820.98|1097.93|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2820.98||||2820.98|1946.48|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2820.98||||2820.98|1128.39|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2820.98||||2820.98||2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2820.98||||2820.98|1946.48|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2820.98||||2820.98|1410.49|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2820.98||||2820.98|1946.48|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2820.98||||2820.98|0|2143.94|564.2
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]|2820.98||||2820.98|1097.93|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2820.98||||2820.98|0|2143.94|564.2
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]|2820.98||||2820.98|1097.93|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2820.98||||2820.98|1946.48|2143.94|564.2
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]|2820.98||||2820.98|1097.93|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|2820.98||||2820.98|564.2|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|TML [1980]|TML [198000]|2820.98||||2820.98|1946.48|2143.94|564.2
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]|2820.98||||2820.98|1097.93|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2820.98||||2820.98||2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|2820.98||||2820.98||2143.94|564.2
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]|2820.98||||2820.98||2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|2820.98||||2820.98|1946.48|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
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]|2820.98||||2820.98|0|2143.94|564.2
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2820.98||||2820.98||2143.94|564.2
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AARP [1000]|AARP [100000]|4530.64||||4530.64||3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AMBETTER [2930]|AMBETTER [293000]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4530.64||||4530.64|2265.32|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4530.64||||4530.64|3262.06|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4530.64||||4530.64|2265.32|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4530.64||||4530.64|2265.32|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4530.64||||4530.64|3443.29|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|4530.64||||4530.64|1812.26|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4530.64||||4530.64||3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4530.64||||4530.64|2265.32|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|Self-pay|Self-pay|4530.64||||4530.64|906.13|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|TML [1980]|TML [198000]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4530.64||||4530.64|1763.33|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4530.64||||4530.64||3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|UNICARE [2040]|UNICARE [204000]|4530.64||||4530.64||3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4530.64||||4530.64||3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|WEB TPA [2115]|WEB TPA [211500]|4530.64||||4530.64|3126.14|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4530.64||||4530.64|0|3443.29|906.13
22953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRINZOLAMIDE 1 % EYE DROPS,SUSPENSION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|4530.64||||4530.64||3443.29|906.13
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AARP [1000]|AARP [100000]|660||||660||501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AMBETTER [2930]|AMBETTER [293000]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|660||||660|330|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|660||||660|475.2|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|660||||660|330|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|660||||660|330|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|660||||660|501.6|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA PPO [126025]|660||||660|264|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|660||||660||501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|660||||660|330|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|Self-pay|Self-pay|660||||660|132|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|TML [1980]|TML [198000]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|660||||660|256.87|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|660||||660||501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|UNICARE [2040]|UNICARE [204000]|660||||660||501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|660||||660||501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|WEB TPA [2115]|WEB TPA [211500]|660||||660|455.4|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|660||||660|0|501.6|132
22982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TML WC [212537]|660||||660||501.6|132
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AARP [1000]|AARP [100000]|4169.49||||4169.49||3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AMBETTER [2930]|AMBETTER [293000]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4169.49||||4169.49|2084.75|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4169.49||||4169.49|1622.77|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|3002.03|3168.81|833.9
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]|4169.49||||4169.49|2084.75|3168.81|833.9
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]|4169.49||||4169.49|2084.75|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4169.49||||4169.49|3168.81|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4169.49||||4169.49|2876.95|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|4169.49||||4169.49|1667.8|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4169.49||||4169.49||3168.81|833.9
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]|4169.49||||4169.49|2876.95|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4169.49||||4169.49|2084.75|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4169.49||||4169.49|2876.95|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4169.49||||4169.49|2876.95|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|Self-pay|Self-pay|4169.49||||4169.49|833.9|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|TML [1980]|TML [198000]|4169.49||||4169.49|2876.95|3168.81|833.9
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]|4169.49||||4169.49|1622.77|3168.81|833.9
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]|4169.49||||4169.49||3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UNICARE [2040]|UNICARE [204000]|4169.49||||4169.49||3168.81|833.9
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]|4169.49||||4169.49||3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|WEB TPA [2115]|WEB TPA [211500]|4169.49||||4169.49|2876.95|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
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]|4169.49||||4169.49|0|3168.81|833.9
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|4169.49||||4169.49||3168.81|833.9
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AARP [1000]|AARP [100000]|739.14||||739.14||561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AETNA [1015]|AETNA [101529]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AMBETTER [2930]|AMBETTER [293000]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|739.14||||739.14|3.13|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|739.14||||739.14|532.18|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|739.14||||739.14|369.57|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|739.14||||739.14|369.57|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|739.14||||739.14|561.75|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|739.14||||739.14|295.66|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|739.14||||739.14||561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|739.14||||739.14|3.13|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|Self-pay|Self-pay|739.14||||739.14|147.83|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|TML [1980]|TML [198000]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|739.14||||739.14|287.67|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|739.14||||739.14||561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|UNICARE [2040]|UNICARE [204000]|739.14||||739.14||561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|739.14||||739.14||561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|WEB TPA [2115]|WEB TPA [211500]|739.14||||739.14|510.01|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|739.14||||739.14|0|561.75|3.13
23049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|739.14||||739.14||561.75|3.13
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|148.5||||148.5||210.67|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]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|148.5||||148.5|0|210.67|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]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|148.5||||148.5|0.05|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5|0|210.67|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]|148.5||||148.5|106.92|210.67|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]|148.5||||148.5|74.25|210.67|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]|148.5||||148.5|74.25|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|148.5||||148.5|112.86|210.67|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]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|148.5||||148.5|102.47|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|148.5||||148.5|59.4|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|148.5||||148.5||210.67|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]|148.5||||148.5|102.47|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|148.5||||148.5|0.05|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|148.5||||148.5|102.47|210.67|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]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|148.5||||148.5|0|210.67|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]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5|0|210.67|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]|148.5||||148.5|0|210.67|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]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5|102.47|210.67|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]|148.5||||148.5|57.8|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|148.5||||148.5|29.7|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|148.5||||148.5|102.47|210.67|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]|148.5||||148.5|57.8|210.67|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]|148.5||||148.5||210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|148.5||||148.5||210.67|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]|148.5||||148.5||210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|148.5||||148.5|102.47|210.67|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]|148.5||||148.5|0|210.67|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]|148.5||||148.5|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|148.5||||148.5||210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|277.2||||277.2||210.67|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]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|0|210.67|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]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|0.05|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2|0|210.67|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]|277.2||||277.2|199.58|210.67|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]|277.2||||277.2|138.6|210.67|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]|277.2||||277.2|138.6|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|210.67|210.67|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]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2||210.67|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]|277.2||||277.2|191.27|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|0.05|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|210.67|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]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|0|210.67|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]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2|0|210.67|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]|277.2||||277.2|0|210.67|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]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2|191.27|210.67|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]|277.2||||277.2|107.89|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|277.2||||277.2|55.44|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|277.2||||277.2|191.27|210.67|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]|277.2||||277.2|107.89|210.67|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]|277.2||||277.2||210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|277.2||||277.2||210.67|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]|277.2||||277.2||210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|210.67|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]|277.2||||277.2|0|210.67|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]|277.2||||277.2|0|210.67|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2||210.67|0.05
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.08||||4.08||3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.08||||4.08|2.04|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.08||||4.08|1.59|3.1|0.82
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]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.08||||4.08|2.94|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.08||||4.08|2.04|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.08||||4.08|2.04|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.08||||4.08|3.1|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.08||||4.08|2.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.08||||4.08|1.63|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.08||||4.08||3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.08||||4.08|2.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.08||||4.08|2.04|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.08||||4.08|2.82|3.1|0.82
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]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.08||||4.08|0|3.1|0.82
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]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.08||||4.08|2.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|4.08||||4.08|0.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.08||||4.08|2.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.08||||4.08|1.59|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.08||||4.08||3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.08||||4.08||3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.08||||4.08||3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.08||||4.08|2.82|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.08||||4.08|0|3.1|0.82
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]|4.08||||4.08|0|3.1|0.82
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.08||||4.08||3.1|0.82
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.26||||13.26||10.08|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]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.26||||13.26|5.16|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.26||||13.26|0.14|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.26||||13.26|5.16|10.08|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]|13.26||||13.26|0|10.08|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]|13.26||||13.26|9.55|10.08|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]|13.26||||13.26|6.63|10.08|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]|13.26||||13.26|6.63|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.26||||13.26|10.08|10.08|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]|13.26||||13.26|5.16|10.08|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]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.26||||13.26|9.15|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.26||||13.26|5.3|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.26||||13.26||10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.26||||13.26|9.15|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.26||||13.26|0.14|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.26||||13.26|9.15|10.08|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]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.26||||13.26|5.16|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.26||||13.26|0|10.08|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]|13.26||||13.26|5.16|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.26||||13.26|9.15|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.26||||13.26|5.16|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|13.26||||13.26|2.65|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.26||||13.26|9.15|10.08|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]|13.26||||13.26|5.16|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.26||||13.26||10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.26||||13.26||10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.26||||13.26||10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.26||||13.26|9.15|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.26||||13.26|0|10.08|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]|13.26||||13.26|0|10.08|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.26||||13.26||10.08|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]|18.87||||18.87|9.44|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|0|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|18.87||||18.87|0|14.34|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]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|0|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.87||||18.87|0.18|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|13.59|14.34|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]|18.87||||18.87|9.44|14.34|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]|18.87||||18.87|9.44|14.34|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 TRADITIONAL OF TEXAS [115503]|18.87||||18.87|14.34|14.34|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]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|0|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.87||||18.87|13.02|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|18.87||||18.87|7.55|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.87||||18.87|9.44|14.34|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]|18.87||||18.87|13.02|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.87||||18.87|0.18|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.87||||18.87|13.02|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|13.02|14.34|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]|18.87||||18.87|7.34|14.34|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|18.87||||18.87|3.77|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|18.87||||18.87|13.02|14.34|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]|18.87||||18.87|7.34|14.34|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]|18.87||||18.87|9.44|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|18.87||||18.87|9.44|14.34|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]|18.87||||18.87|9.44|14.34|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|18.87||||18.87|13.02|14.34|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]|18.87||||18.87|0|14.34|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]|18.87||||18.87|0|14.34|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]|TML WC [212537]|18.87||||18.87|9.44|14.34|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]|10.3||||10.3|5.15|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|0|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|10.3||||10.3|0|7.83|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]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|0|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.3||||10.3|0.18|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|7.42|7.83|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]|10.3||||10.3|5.15|7.83|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]|10.3||||10.3|5.15|7.83|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 TRADITIONAL OF TEXAS [115503]|10.3||||10.3|7.83|7.83|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]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|0|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.3||||10.3|7.11|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|10.3||||10.3|4.12|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.3||||10.3|5.15|7.83|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]|10.3||||10.3|7.11|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.3||||10.3|0.18|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.3||||10.3|7.11|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|7.11|7.83|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]|10.3||||10.3|4.01|7.83|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|10.3||||10.3|2.06|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|10.3||||10.3|7.11|7.83|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]|10.3||||10.3|4.01|7.83|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]|10.3||||10.3|5.15|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|10.3||||10.3|5.15|7.83|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]|10.3||||10.3|5.15|7.83|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|10.3||||10.3|7.11|7.83|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]|10.3||||10.3|0|7.83|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]|10.3||||10.3|0|7.83|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]|TML WC [212537]|10.3||||10.3|5.15|7.83|0.18
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|711.48||||711.48||540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|711.48||||711.48|355.74|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|711.48||||711.48|512.27|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|711.48||||711.48|355.74|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|711.48||||711.48|355.74|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|711.48||||711.48|540.72|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|711.48||||711.48|284.59|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|711.48||||711.48||540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|711.48||||711.48|355.74|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|711.48||||711.48|142.3|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|711.48||||711.48|276.91|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|711.48||||711.48||540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|711.48||||711.48||540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|711.48||||711.48||540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|711.48||||711.48|490.92|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|711.48||||711.48|0|540.72|142.3
2335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|711.48||||711.48||540.72|142.3
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AARP [1000]|AARP [100000]|66||||66||50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66||50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|Self-pay|Self-pay|66||||66|13.2|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|TML [1980]|TML [198000]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNICARE [2040]|UNICARE [204000]|66||||66||50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66|0|50.16|13.2
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WORKER'S COMP [2125]|TML WC [212537]|66||||66||50.16|13.2
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6||30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|28.51|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|19.8|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|15.41|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6||30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6|0|30.1|7.92
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||30.1|7.92
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|66||||66||50.16|2.57
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]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|5.11|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|2.57
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]|66||||66|0|50.16|2.57
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]|66||||66|47.52|50.16|2.57
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]|66||||66|33|50.16|2.57
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]|66||||66|33|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|2.57
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]|66||||66|25.69|50.16|2.57
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]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66||50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|5.11|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|2.57
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]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|2.57
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]|66||||66|25.69|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|66||||66|13.2|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|50.16|2.57
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]|66||||66|25.69|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66||50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|50.16|2.57
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]|66||||66|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66||50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AARP [1000]|AARP [100000]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA [1015]|AETNA [101529]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMBETTER [2930]|AMBETTER [293000]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|49.5||||49.5|2.57|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.5||||49.5|35.64|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|49.5||||49.5|37.62|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA PPO [126025]|49.5||||49.5|19.8|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|49.5||||49.5|2.57|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|Self-pay|Self-pay|49.5||||49.5|9.9|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|TML [1980]|TML [198000]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.5||||49.5|19.27|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UNICARE [2040]|UNICARE [204000]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.5||||49.5|24.75|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WEB TPA [2115]|WEB TPA [211500]|49.5||||49.5|34.16|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.5||||49.5|0|50.16|2.57
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TML WC [212537]|49.5||||49.5|24.75|50.16|2.57
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|36.53||||36.53||27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.53||||36.53|18.27|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.53||||36.53|26.3|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.53||||36.53|18.27|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.53||||36.53|18.27|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.53||||36.53|27.76|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|36.53||||36.53|14.61|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.53||||36.53||27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.53||||36.53|18.27|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|36.53||||36.53|7.31|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.53||||36.53|14.22|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.53||||36.53||27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|36.53||||36.53||27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.53||||36.53||27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|36.53||||36.53|25.21|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.53||||36.53|0|27.76|7.31
23873|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEFLUNOMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|36.53||||36.53||27.76|7.31
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AARP [1000]|AARP [100000]|1914||||1914||1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|AETNA [101529]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1914||||1914|957|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1914||||1914|1378.08|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1914||||1914|957|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1914||||1914|957|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1914||||1914|1454.64|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|1914||||1914|765.6|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1914||||1914||1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1914||||1914|957|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|Self-pay|Self-pay|1914||||1914|382.8|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|TML [1980]|TML [198000]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1914||||1914|744.93|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1914||||1914||1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|1914||||1914||1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1914||||1914||1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|1914||||1914|1320.66|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1914||||1914|0|1454.64|382.8
23968|ERX|0250 - PHARMACY-GENERAL|MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|1914||||1914||1454.64|382.8
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.85||||0.85||0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.85||||0.85|0.43|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.85||||0.85|0.33|0.65|0.17
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]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.85||||0.85|0.61|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.85||||0.85|0.43|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.85||||0.85|0.43|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.85||||0.85|0.65|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.85||||0.85|0.59|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.85||||0.85|0.34|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.85||||0.85||0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.85||||0.85|0.59|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.85||||0.85|0.43|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.85||||0.85|0.59|0.65|0.17
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]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.85||||0.85|0|0.65|0.17
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]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.85||||0.85|0.59|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.85||||0.85|0.17|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.85||||0.85|0.59|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.85||||0.85|0.33|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.85||||0.85||0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.85||||0.85||0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.85||||0.85||0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.85||||0.85|0.59|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.85||||0.85|0|0.65|0.17
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]|0.85||||0.85|0|0.65|0.17
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.85||||0.85||0.65|0.17
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.64||||0.64||0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.64||||0.64|0.32|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.64||||0.64|0.46|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.64||||0.64|0.32|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.64||||0.64|0.32|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.64||||0.64|0.49|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.64||||0.64|0.26|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.64||||0.64||0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.64||||0.64|0.32|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.64||||0.64|0.13|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.64||||0.64|0.25|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.64||||0.64||0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.64||||0.64||0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.64||||0.64||0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.64||||0.64|0.44|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.64||||0.64|0|0.49|0.13
2405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.64||||0.64||0.49|0.13
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AARP [1000]|AARP [100000]|1108.8||||1108.8||842.69|45.03
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]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1108.8||||1108.8|431.54|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1108.8||||1108.8|45.03|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1108.8||||1108.8|431.54|842.69|45.03
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]|1108.8||||1108.8|0|842.69|45.03
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]|1108.8||||1108.8|798.34|842.69|45.03
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]|1108.8||||1108.8|554.4|842.69|45.03
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]|1108.8||||1108.8|554.4|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1108.8||||1108.8|842.69|842.69|45.03
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]|1108.8||||1108.8|431.54|842.69|45.03
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]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1108.8||||1108.8|765.07|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|1108.8||||1108.8|443.52|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1108.8||||1108.8||842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1108.8||||1108.8|765.07|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1108.8||||1108.8|45.03|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1108.8||||1108.8|765.07|842.69|45.03
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]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1108.8||||1108.8|431.54|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1108.8||||1108.8|0|842.69|45.03
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]|1108.8||||1108.8|431.54|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1108.8||||1108.8|765.07|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1108.8||||1108.8|431.54|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|Self-pay|Self-pay|1108.8||||1108.8|221.76|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|TML [1980]|TML [198000]|1108.8||||1108.8|765.07|842.69|45.03
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]|1108.8||||1108.8|431.54|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1108.8||||1108.8||842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|1108.8||||1108.8||842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1108.8||||1108.8||842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|1108.8||||1108.8|765.07|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1108.8||||1108.8|0|842.69|45.03
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]|1108.8||||1108.8|0|842.69|45.03
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|1108.8||||1108.8||842.69|45.03
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.56||||5.56||4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.56||||5.56|2.78|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.56||||5.56|4|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.56||||5.56|2.78|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.56||||5.56|2.78|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.56||||5.56|4.23|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.56||||5.56|2.22|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.56||||5.56||4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.56||||5.56|2.78|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|Self-pay|Self-pay|5.56||||5.56|1.11|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.56||||5.56|2.16|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.56||||5.56||4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.56||||5.56||4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.56||||5.56||4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.56||||5.56|3.84|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.56||||5.56|0|4.23|1.11
24216|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.56||||5.56||4.23|1.11
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]|9.21||||9.21||7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|0|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21|0|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.21||||9.21|4.61|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|6.63|7|1.84
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]|9.21||||9.21|4.61|7|1.84
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]|9.21||||9.21|4.61|7|1.84
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 TRADITIONAL OF TEXAS [115503]|9.21||||9.21|7|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21|0|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.21||||9.21|6.35|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.21||||9.21|3.68|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.21||||9.21||7|1.84
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]|9.21||||9.21|6.35|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.21||||9.21|4.61|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.21||||9.21|6.35|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21|6.35|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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|9.21||||9.21|1.84|7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|9.21||||9.21|6.35|7|1.84
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]|9.21||||9.21|3.58|7|1.84
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]|9.21||||9.21||7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|9.21||||9.21||7|1.84
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]|9.21||||9.21||7|1.84
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.21||||9.21|6.35|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|9.21||||9.21|0|7|1.84
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]|TML WC [212537]|9.21||||9.21||7|1.84
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|15.65||||15.65||11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.65||||15.65|6.09|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.65||||15.65|7.83|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.65||||15.65|6.09|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
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]|15.65||||15.65|11.27|11.89|3.13
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]|15.65||||15.65|7.83|11.89|3.13
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]|15.65||||15.65|7.83|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.65||||15.65|11.89|11.89|3.13
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]|15.65||||15.65|6.09|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.65||||15.65|10.8|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.65||||15.65|6.26|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.65||||15.65||11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.65||||15.65|10.8|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.65||||15.65|7.83|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.65||||15.65|10.8|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.65||||15.65|0|11.89|3.13
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]|15.65||||15.65|6.09|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.65||||15.65|0|11.89|3.13
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]|15.65||||15.65|6.09|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.65||||15.65|10.8|11.89|3.13
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]|15.65||||15.65|6.09|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|Self-pay|Self-pay|15.65||||15.65|3.13|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|TML [1980]|TML [198000]|15.65||||15.65|10.8|11.89|3.13
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]|15.65||||15.65|6.09|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.65||||15.65||11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.65||||15.65||11.89|3.13
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]|15.65||||15.65||11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.65||||15.65|10.8|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
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]|15.65||||15.65|0|11.89|3.13
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.65||||15.65||11.89|3.13
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]|36.03||||36.03||27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.03||||36.03|18.02|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|25.94|27.38|7.21
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]|36.03||||36.03|18.02|27.38|7.21
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]|36.03||||36.03|18.02|27.38|7.21
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 TRADITIONAL OF TEXAS [115503]|36.03||||36.03|27.38|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.03||||36.03|24.86|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|36.03||||36.03|14.41|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.03||||36.03||27.38|7.21
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]|36.03||||36.03|24.86|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.03||||36.03|18.02|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.03||||36.03|24.86|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03|24.86|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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|36.03||||36.03|7.21|27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|36.03||||36.03|24.86|27.38|7.21
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]|36.03||||36.03|14.02|27.38|7.21
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]|36.03||||36.03||27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|36.03||||36.03||27.38|7.21
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]|36.03||||36.03||27.38|7.21
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|36.03||||36.03|24.86|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|36.03||||36.03|0|27.38|7.21
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]|TML WC [212537]|36.03||||36.03||27.38|7.21
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.2||||4.2||3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.2||||4.2|2.1|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.2||||4.2|1.63|3.19|0.84
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]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.2||||4.2|3.02|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.2||||4.2|2.1|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.2||||4.2|2.1|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.2||||4.2|3.19|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.2||||4.2|2.9|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.2||||4.2|1.68|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.2||||4.2||3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.2||||4.2|2.9|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.2||||4.2|2.1|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.2||||4.2|2.9|3.19|0.84
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]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.2||||4.2|0|3.19|0.84
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]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.2||||4.2|2.9|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|4.2||||4.2|0.84|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.2||||4.2|2.9|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.2||||4.2|1.63|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.2||||4.2||3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.2||||4.2||3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.2||||4.2||3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.2||||4.2|2.9|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.2||||4.2|0|3.19|0.84
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]|4.2||||4.2|0|3.19|0.84
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.2||||4.2||3.19|0.84
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.82||||4.82||3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.82||||4.82|2.41|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.82||||4.82|3.47|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.82||||4.82|2.41|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.82||||4.82|2.41|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.82||||4.82|3.66|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.82||||4.82|1.93|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.82||||4.82||3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.82||||4.82|2.41|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.82||||4.82|0.96|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.82||||4.82|1.88|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.82||||4.82||3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.82||||4.82||3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.82||||4.82||3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.82||||4.82|3.33|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.82||||4.82|0|3.66|0.96
24474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.82||||4.82||3.66|0.96
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|15.88||||15.88||12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.88||||15.88|7.94|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.88||||15.88|11.43|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.88||||15.88|7.94|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.88||||15.88|7.94|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.88||||15.88|12.07|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|15.88||||15.88|6.35|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.88||||15.88||12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.88||||15.88|7.94|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|15.88||||15.88|3.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.88||||15.88|6.18|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.88||||15.88||12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|15.88||||15.88||12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.88||||15.88||12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|15.88||||15.88|10.96|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.88||||15.88|0|12.07|3.18
24500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CELECOXIB 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|15.88||||15.88||12.07|3.18
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]|9.1||||9.1||6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.1||||9.1|4.55|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|6.55|6.92|1.82
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]|9.1||||9.1|4.55|6.92|1.82
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]|9.1||||9.1|4.55|6.92|1.82
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 TRADITIONAL OF TEXAS [115503]|9.1||||9.1|6.92|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.1||||9.1|6.28|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.1||||9.1|3.64|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.1||||9.1||6.92|1.82
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]|9.1||||9.1|6.28|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.1||||9.1|4.55|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.1||||9.1|6.28|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1|6.28|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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|9.1||||9.1|1.82|6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|9.1||||9.1|6.28|6.92|1.82
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]|9.1||||9.1|3.54|6.92|1.82
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]|9.1||||9.1||6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|9.1||||9.1||6.92|1.82
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]|9.1||||9.1||6.92|1.82
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.1||||9.1|6.28|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|9.1||||9.1|0|6.92|1.82
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]|TML WC [212537]|9.1||||9.1||6.92|1.82
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.18||||0.18||0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.18||||0.18|0.09|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.18||||0.18|0.07|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0.13|0.14|0.04
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]|0.18||||0.18|0.09|0.14|0.04
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]|0.18||||0.18|0.09|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.18||||0.18|0.14|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.18||||0.18|0.12|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.18||||0.18|0.07|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.18||||0.18||0.14|0.04
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]|0.18||||0.18|0.12|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.18||||0.18|0.09|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.18||||0.18|0.12|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|Self-pay|Self-pay|0.18||||0.18|0.04|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|TML [1980]|TML [198000]|0.18||||0.18|0.12|0.14|0.04
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]|0.18||||0.18|0.07|0.14|0.04
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]|0.18||||0.18||0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.18||||0.18||0.14|0.04
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]|0.18||||0.18||0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.18||||0.18|0.12|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
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]|0.18||||0.18|0|0.14|0.04
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.18||||0.18||0.14|0.04
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|353.26||||353.26||268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|353.26||||353.26|176.63|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|353.26||||353.26|254.35|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|353.26||||353.26|176.63|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|353.26||||353.26|176.63|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|353.26||||353.26|268.48|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|353.26||||353.26|141.3|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|353.26||||353.26||268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|353.26||||353.26|176.63|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|353.26||||353.26|70.65|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|353.26||||353.26|137.49|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|353.26||||353.26||268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|353.26||||353.26||268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|353.26||||353.26||268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|353.26||||353.26|243.75|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|353.26||||353.26|0|268.48|70.65
24731|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|353.26||||353.26||268.48|70.65
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.98||||1.98||1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.98||||1.98|0.99|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.98||||1.98|0.77|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.98||||1.98|1.43|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.98||||1.98|0.99|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.98||||1.98|0.99|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.98||||1.98|1.5|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.98||||1.98|1.37|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.98||||1.98|0.79|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.98||||1.98||1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.98||||1.98|1.37|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.98||||1.98|0.99|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.98||||1.98|1.37|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.98||||1.98|0|1.5|0.4
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]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.98||||1.98|1.37|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|Self-pay|Self-pay|1.98||||1.98|0.4|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.98||||1.98|1.37|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.98||||1.98|0.77|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.98||||1.98||1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.98||||1.98||1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.98||||1.98||1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.98||||1.98|1.37|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.98||||1.98|0|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.98||||1.98||1.5|0.4
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.11||||3.11||2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.11||||3.11|1.56|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.11||||3.11|1.21|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.11||||3.11|2.24|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.11||||3.11|1.56|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.11||||3.11|1.56|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.11||||3.11|2.36|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.11||||3.11|2.15|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.11||||3.11|1.24|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.11||||3.11||2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.11||||3.11|2.15|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.11||||3.11|1.56|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.11||||3.11|2.15|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.11||||3.11|0|2.36|0.62
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]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.11||||3.11|2.15|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|Self-pay|Self-pay|3.11||||3.11|0.62|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.11||||3.11|2.15|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.11||||3.11|1.21|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.11||||3.11||2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.11||||3.11||2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.11||||3.11||2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.11||||3.11|2.15|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.11||||3.11|0|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.11||||3.11||2.36|0.62
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|6.1||||6.1||4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.1||||6.1|2.37|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.1||||6.1|0.78|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.1||||6.1|2.37|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
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]|6.1||||6.1|4.39|4.64|0.78
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]|6.1||||6.1|3.05|4.64|0.78
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]|6.1||||6.1|3.05|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.1||||6.1|4.64|4.64|0.78
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]|6.1||||6.1|2.37|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.1||||6.1|4.21|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|6.1||||6.1|2.44|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.1||||6.1||4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.1||||6.1|4.21|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.1||||6.1|0.78|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.1||||6.1|4.21|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.1||||6.1|0|4.64|0.78
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]|6.1||||6.1|2.37|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.1||||6.1|0|4.64|0.78
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]|6.1||||6.1|2.37|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.1||||6.1|4.21|4.64|0.78
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]|6.1||||6.1|2.37|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|6.1||||6.1|1.22|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TML [1980]|TML [198000]|6.1||||6.1|4.21|4.64|0.78
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]|6.1||||6.1|2.37|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.1||||6.1||4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|6.1||||6.1||4.64|0.78
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]|6.1||||6.1||4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|6.1||||6.1|4.21|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
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]|6.1||||6.1|0|4.64|0.78
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|6.1||||6.1||4.64|0.78
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]|419.76||||419.76||319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMBETTER [2930]|AMBETTER [293000]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|419.76||||419.76|209.88|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|302.23|319.02|83.95
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]|419.76||||419.76|209.88|319.02|83.95
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]|419.76||||419.76|209.88|319.02|83.95
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 TRADITIONAL OF TEXAS [115503]|419.76||||419.76|319.02|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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 - GREAT WEST [126009]|419.76||||419.76|289.63|319.02|83.95
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 PPO [126025]|419.76||||419.76|167.9|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|419.76||||419.76||319.02|83.95
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]|419.76||||419.76|289.63|319.02|83.95
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|419.76||||419.76|209.88|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|419.76||||419.76|289.63|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76|289.63|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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|419.76||||419.76|83.95|319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|TML [1980]|TML [198000]|419.76||||419.76|289.63|319.02|83.95
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]|419.76||||419.76|163.37|319.02|83.95
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]|419.76||||419.76||319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNICARE [2040]|UNICARE [204000]|419.76||||419.76||319.02|83.95
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]|419.76||||419.76||319.02|83.95
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WEB TPA [2115]|WEB TPA [211500]|419.76||||419.76|289.63|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|419.76||||419.76|0|319.02|83.95
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]|TML WC [212537]|419.76||||419.76||319.02|83.95
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AARP [1000]|AARP [100000]|2.66||||2.66||2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AETNA [1015]|AETNA [101529]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMBETTER [2930]|AMBETTER [293000]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.66||||2.66|1.33|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.66||||2.66|1.92|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.66||||2.66|1.33|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.66||||2.66|1.33|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.66||||2.66|2.02|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|2.66||||2.66|1.06|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.66||||2.66||2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.66||||2.66|1.33|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|Self-pay|Self-pay|2.66||||2.66|0.53|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|TML [1980]|TML [198000]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.66||||2.66|1.04|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.66||||2.66||2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UNICARE [2040]|UNICARE [204000]|2.66||||2.66||2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.66||||2.66||2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WEB TPA [2115]|WEB TPA [211500]|2.66||||2.66|1.84|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.66||||2.66|0|2.02|0.53
250|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|2.66||||2.66||2.02|0.53
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|7.26||||7.26|3.63|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.26||||7.26|2.83|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.26||||7.26|0.81|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.26||||7.26|2.83|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
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]|7.26||||7.26|5.23|5.52|0.81
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]|7.26||||7.26|3.63|5.52|0.81
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]|7.26||||7.26|3.63|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.26||||7.26|5.52|5.52|0.81
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]|7.26||||7.26|2.83|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.26||||7.26|5.01|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|7.26||||7.26|2.9|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.26||||7.26|3.63|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.26||||7.26|5.01|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.26||||7.26|0.81|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.26||||7.26|5.01|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.26||||7.26|0|5.52|0.81
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]|7.26||||7.26|2.83|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.26||||7.26|0|5.52|0.81
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]|7.26||||7.26|2.83|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.26||||7.26|5.01|5.52|0.81
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]|7.26||||7.26|2.83|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|7.26||||7.26|1.45|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|7.26||||7.26|5.01|5.52|0.81
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]|7.26||||7.26|2.83|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.26||||7.26|3.63|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|7.26||||7.26|3.63|5.52|0.81
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]|7.26||||7.26|3.63|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|7.26||||7.26|5.01|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
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]|7.26||||7.26|0|5.52|0.81
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|7.26||||7.26|3.63|5.52|0.81
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.45||||0.45||0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.45||||0.45|0.23|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.45||||0.45|0.18|0.34|0.09
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]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.45||||0.45|0.32|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.45||||0.45|0.23|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.45||||0.45|0.23|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.45||||0.45|0.34|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.45||||0.45|0.31|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.45||||0.45||0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.45||||0.45|0.31|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.45||||0.45|0.23|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.45||||0.45|0.31|0.34|0.09
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]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.45||||0.45|0|0.34|0.09
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]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.45||||0.45|0.31|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.45||||0.45|0.09|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|0.45||||0.45|0.31|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.45||||0.45|0.18|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.45||||0.45||0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|0.45||||0.45||0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.45||||0.45||0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|0.45||||0.45|0.31|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.45||||0.45|0|0.34|0.09
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]|0.45||||0.45|0|0.34|0.09
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|0.45||||0.45||0.34|0.09
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AARP [1000]|AARP [100000]|39.41||||39.41||29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AETNA [1015]|AETNA [101529]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AMBETTER [2930]|AMBETTER [293000]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.41||||39.41|19.71|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.41||||39.41|28.38|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.41||||39.41|19.71|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.41||||39.41|19.71|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.41||||39.41|29.95|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|CIGNA [1260]|CIGNA PPO [126025]|39.41||||39.41|15.76|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.41||||39.41||29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.41||||39.41|19.71|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|Self-pay|Self-pay|39.41||||39.41|7.88|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|TML [1980]|TML [198000]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.41||||39.41|15.34|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.41||||39.41||29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|UNICARE [2040]|UNICARE [204000]|39.41||||39.41||29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.41||||39.41||29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|WEB TPA [2115]|WEB TPA [211500]|39.41||||39.41|27.19|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.41||||39.41|0|29.95|7.88
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|5 mL|WORKER'S COMP [2125]|TML WC [212537]|39.41||||39.41||29.95|7.88
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.24||||9.24||7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.24||||9.24|4.62|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|6.65|7.02|1.85
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]|9.24||||9.24|4.62|7.02|1.85
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]|9.24||||9.24|4.62|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.24||||9.24|7.02|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.24||||9.24|6.38|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.24||||9.24|3.7|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.24||||9.24||7.02|1.85
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]|9.24||||9.24|6.38|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.24||||9.24|4.62|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|Self-pay|Self-pay|9.24||||9.24|1.85|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24||7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.24||||9.24||7.02|1.85
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]|9.24||||9.24||7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.24||||9.24||7.02|1.85
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.07||||13.07||9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.07||||13.07|6.54|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.07||||13.07|9.41|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.07||||13.07|6.54|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.07||||13.07|6.54|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.07||||13.07|9.93|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.07||||13.07|5.23|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.07||||13.07||9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.07||||13.07|6.54|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|Self-pay|Self-pay|13.07||||13.07|2.61|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.07||||13.07|5.09|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.07||||13.07||9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.07||||13.07||9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.07||||13.07||9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.07||||13.07|9.02|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.07||||13.07|0|9.93|2.61
254|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.07||||13.07||9.93|2.61
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|19.88||||19.88||15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.88||||19.88|9.94|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.88||||19.88|14.31|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.88||||19.88|9.94|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.88||||19.88|9.94|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.88||||19.88|15.11|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|19.88||||19.88|7.95|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.88||||19.88||15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.88||||19.88|9.94|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|19.88||||19.88|3.98|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.88||||19.88|7.74|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.88||||19.88||15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|19.88||||19.88||15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.88||||19.88||15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|19.88||||19.88|13.72|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.88||||19.88|0|15.11|3.98
25424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|19.88||||19.88||15.11|3.98
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65||1.25|0.33
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]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0.64|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.65||||1.65|0.83|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.65||||1.65|0.64|1.25|0.33
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]|1.65||||1.65|0|1.25|0.33
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]|1.65||||1.65|1.19|1.25|0.33
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]|1.65||||1.65|0.83|1.25|0.33
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]|1.65||||1.65|0.83|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.65||||1.65|1.25|1.25|0.33
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]|1.65||||1.65|0.64|1.25|0.33
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]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.65||||1.65|1.14|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.65||||1.65|0.66|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.65||||1.65||1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.65||||1.65|0.83|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.65||||1.65|1.14|1.25|0.33
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]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0.64|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0|1.25|0.33
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]|1.65||||1.65|0.64|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0.64|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.33|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|1.65||||1.65|1.14|1.25|0.33
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]|1.65||||1.65|0.64|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65||1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|1.65||||1.65||1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65||1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.65||||1.65|1.14|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65|0|1.25|0.33
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]|1.65||||1.65|0|1.25|0.33
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.65||||1.65||1.25|0.33
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.44||||21.44||16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.44||||21.44|10.72|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.44||||21.44|8.34|16.29|4.29
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]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.44||||21.44|15.44|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.44||||21.44|10.72|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.44||||21.44|10.72|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.44||||21.44|16.29|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.44||||21.44|14.79|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.44||||21.44|8.58|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.44||||21.44||16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.44||||21.44|14.79|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.44||||21.44|10.72|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.44||||21.44|14.79|16.29|4.29
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]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.44||||21.44|0|16.29|4.29
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]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.44||||21.44|14.79|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|Self-pay|Self-pay|21.44||||21.44|4.29|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.44||||21.44|14.79|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.44||||21.44|8.34|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.44||||21.44||16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.44||||21.44||16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.44||||21.44||16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.44||||21.44|14.79|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.44||||21.44|0|16.29|4.29
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]|21.44||||21.44|0|16.29|4.29
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.44||||21.44||16.29|4.29
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.96||||0.96||0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.96||||0.96|0.48|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.96||||0.96|0.69|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.96||||0.96|0.48|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.96||||0.96|0.48|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.96||||0.96|0.73|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|0.96||||0.96|0.38|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.96||||0.96||0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.96||||0.96|0.48|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.96||||0.96|0.19|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.96||||0.96|0.37|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.96||||0.96||0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|0.96||||0.96||0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.96||||0.96||0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|0.96||||0.96|0.66|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.96||||0.96|0|0.73|0.19
2565|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE CALCIUM 240 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|0.96||||0.96||0.73|0.19
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]|38.61||||38.61||29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.61||||38.61|0.86|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|27.8|29.34|0.86
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]|38.61||||38.61|19.31|29.34|0.86
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]|38.61||||38.61|19.31|29.34|0.86
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 TRADITIONAL OF TEXAS [115503]|38.61||||38.61|29.34|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.61||||38.61|26.64|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|38.61||||38.61|15.44|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.61||||38.61||29.34|0.86
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]|38.61||||38.61|26.64|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.61||||38.61|0.86|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.61||||38.61|26.64|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61|26.64|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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|38.61||||38.61|7.72|29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|38.61||||38.61|26.64|29.34|0.86
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]|38.61||||38.61|15.03|29.34|0.86
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]|38.61||||38.61||29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|38.61||||38.61||29.34|0.86
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]|38.61||||38.61||29.34|0.86
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|38.61||||38.61|26.64|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|38.61||||38.61|0|29.34|0.86
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]|TML WC [212537]|38.61||||38.61||29.34|0.86
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.04||||7.04||5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.04||||7.04|3.52|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.04||||7.04|2.74|5.35|1.41
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]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.04||||7.04|5.07|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.04||||7.04|3.52|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.04||||7.04|3.52|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.04||||7.04|5.35|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.04||||7.04|4.86|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.04||||7.04|2.82|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.04||||7.04||5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.04||||7.04|4.86|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.04||||7.04|3.52|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.04||||7.04|4.86|5.35|1.41
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]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.04||||7.04|0|5.35|1.41
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]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.04||||7.04|4.86|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.04||||7.04|1.41|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.04||||7.04|4.86|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.04||||7.04|2.74|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.04||||7.04||5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.04||||7.04||5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.04||||7.04||5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.04||||7.04|4.86|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.04||||7.04|0|5.35|1.41
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]|7.04||||7.04|0|5.35|1.41
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.04||||7.04||5.35|1.41
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|21.97||||21.97||16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.97||||21.97|10.99|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.97||||21.97|15.82|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.97||||21.97|10.99|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.97||||21.97|10.99|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.97||||21.97|16.7|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|21.97||||21.97|8.79|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.97||||21.97||16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.97||||21.97|10.99|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|21.97||||21.97|4.39|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.97||||21.97|8.55|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.97||||21.97||16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|21.97||||21.97||16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.97||||21.97||16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|21.97||||21.97|15.16|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.97||||21.97|0|16.7|4.39
2609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|21.97||||21.97||16.7|4.39
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|9.27||||9.27||7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.27||||9.27|4.64|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.27||||9.27|3.61|7.05|1.85
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]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.27||||9.27|6.67|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.27||||9.27|4.64|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.27||||9.27|4.64|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.27||||9.27|7.05|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.27||||9.27|6.4|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|9.27||||9.27|3.71|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.27||||9.27||7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|9.27||||9.27|6.4|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.27||||9.27|4.64|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.27||||9.27|6.4|7.05|1.85
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]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.27||||9.27|0|7.05|1.85
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]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|9.27||||9.27|6.4|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|9.27||||9.27|1.85|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|9.27||||9.27|6.4|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.27||||9.27|3.61|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.27||||9.27||7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|9.27||||9.27||7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.27||||9.27||7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|9.27||||9.27|6.4|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.27||||9.27|0|7.05|1.85
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]|9.27||||9.27|0|7.05|1.85
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|9.27||||9.27||7.05|1.85
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AARP [1000]|AARP [100000]|347.56||||347.56||264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMBETTER [2930]|AMBETTER [293000]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|347.56||||347.56|173.78|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|347.56||||347.56|135.27|264.15|69.51
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]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347.56||||347.56|250.24|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347.56||||347.56|173.78|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347.56||||347.56|173.78|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|347.56||||347.56|264.15|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|347.56||||347.56|239.82|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA [1260]|CIGNA PPO [126025]|347.56||||347.56|139.02|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|347.56||||347.56||264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|347.56||||347.56|239.82|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|347.56||||347.56|173.78|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|347.56||||347.56|239.82|264.15|69.51
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]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347.56||||347.56|0|264.15|69.51
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]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|347.56||||347.56|239.82|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|Self-pay|Self-pay|347.56||||347.56|69.51|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|TML [1980]|TML [198000]|347.56||||347.56|239.82|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347.56||||347.56|135.27|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347.56||||347.56||264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNICARE [2040]|UNICARE [204000]|347.56||||347.56||264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347.56||||347.56||264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WEB TPA [2115]|WEB TPA [211500]|347.56||||347.56|239.82|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347.56||||347.56|0|264.15|69.51
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]|347.56||||347.56|0|264.15|69.51
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WORKER'S COMP [2125]|TML WC [212537]|347.56||||347.56||264.15|69.51
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AARP [1000]|AARP [100000]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA [1015]|AETNA [101529]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMBETTER [2930]|AMBETTER [293000]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.33||||66.33|25.82|50.41|13.27
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]|66.33||||66.33|0|50.41|13.27
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]|66.33||||66.33|47.76|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.33||||66.33|33.17|50.41|13.27
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]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.33||||66.33|50.41|50.41|13.27
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]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.33||||66.33|45.77|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA [1260]|CIGNA PPO [126025]|66.33||||66.33|26.53|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|66.33||||66.33|45.77|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.33||||66.33|45.77|50.41|13.27
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]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.33||||66.33|0|50.41|13.27
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]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|66.33||||66.33|45.77|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|Self-pay|Self-pay|66.33||||66.33|13.27|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|TML [1980]|TML [198000]|66.33||||66.33|45.77|50.41|13.27
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]|66.33||||66.33|25.82|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNICARE [2040]|UNICARE [204000]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.33||||66.33|33.17|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WEB TPA [2115]|WEB TPA [211500]|66.33||||66.33|45.77|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.33||||66.33|0|50.41|13.27
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]|66.33||||66.33|0|50.41|13.27
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WORKER'S COMP [2125]|TML WC [212537]|66.33||||66.33|33.17|50.41|13.27
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|15.84||||15.84||12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.84||||15.84|7.92|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.84||||15.84|11.4|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.84||||15.84|7.92|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.84||||15.84|7.92|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.84||||15.84|12.04|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|15.84||||15.84|6.34|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.84||||15.84||12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.84||||15.84|7.92|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|15.84||||15.84|3.17|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.84||||15.84|6.16|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.84||||15.84||12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|15.84||||15.84||12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.84||||15.84||12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|15.84||||15.84|10.93|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.84||||15.84|0|12.04|3.17
2623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|15.84||||15.84||12.04|3.17
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|16.25||||16.25||12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.25||||16.25|8.13|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.25||||16.25|6.32|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|11.7|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.25||||16.25|8.13|12.35|3.25
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]|16.25||||16.25|8.13|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.25||||16.25|12.35|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.25||||16.25|11.21|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|16.25||||16.25|6.5|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.25||||16.25||12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.25||||16.25|11.21|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.25||||16.25|8.13|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.25||||16.25|11.21|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.25||||16.25|11.21|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|16.25||||16.25|3.25|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|16.25||||16.25|11.21|12.35|3.25
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]|16.25||||16.25|6.32|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.25||||16.25||12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|16.25||||16.25||12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.25||||16.25||12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|16.25||||16.25|11.21|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.25||||16.25|0|12.35|3.25
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]|16.25||||16.25|0|12.35|3.25
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|16.25||||16.25||12.35|3.25
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]|11.78||||11.78||8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.78||||11.78|5.89|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|8.48|8.95|2.36
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]|11.78||||11.78|5.89|8.95|2.36
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]|11.78||||11.78|5.89|8.95|2.36
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 TRADITIONAL OF TEXAS [115503]|11.78||||11.78|8.95|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.78||||11.78|8.13|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.78||||11.78|4.71|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.78||||11.78||8.95|2.36
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]|11.78||||11.78|8.13|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.78||||11.78|5.89|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.78||||11.78|8.13|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78|8.13|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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|11.78||||11.78|2.36|8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|11.78||||11.78|8.13|8.95|2.36
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]|11.78||||11.78|4.58|8.95|2.36
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]|11.78||||11.78||8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|11.78||||11.78||8.95|2.36
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]|11.78||||11.78||8.95|2.36
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.78||||11.78|8.13|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|11.78||||11.78|0|8.95|2.36
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]|TML WC [212537]|11.78||||11.78||8.95|2.36
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|59.4||||59.4||45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|29.7|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|23.12|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.4||||59.4|42.77|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.4||||59.4|29.7|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.4||||59.4|29.7|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|45.14|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4||45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|29.7|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|0|45.14|11.88
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]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|59.4||||59.4|11.88|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|59.4||||59.4|40.99|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.4||||59.4|23.12|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4||45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|59.4||||59.4||45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4||45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4|0|45.14|11.88
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]|59.4||||59.4|0|45.14|11.88
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4||45.14|11.88
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|41.72||||41.72||31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.72||||41.72|20.86|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.72||||41.72|16.24|31.71|8.34
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]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.72||||41.72|30.04|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.72||||41.72|20.86|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.72||||41.72|20.86|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.72||||41.72|31.71|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.72||||41.72|28.79|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|41.72||||41.72|16.69|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.72||||41.72||31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.72||||41.72|28.79|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.72||||41.72|20.86|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.72||||41.72|28.79|31.71|8.34
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]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.72||||41.72|0|31.71|8.34
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]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.72||||41.72|28.79|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|41.72||||41.72|8.34|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|41.72||||41.72|28.79|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.72||||41.72|16.24|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.72||||41.72||31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|41.72||||41.72||31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.72||||41.72||31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|41.72||||41.72|28.79|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.72||||41.72|0|31.71|8.34
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]|41.72||||41.72|0|31.71|8.34
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|41.72||||41.72||31.71|8.34
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.69||||7.69||5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.69||||7.69|3.85|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.69||||7.69|5.54|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.69||||7.69|3.85|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.69||||7.69|3.85|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.69||||7.69|5.84|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.69||||7.69|3.08|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.69||||7.69||5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.69||||7.69|3.85|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|Self-pay|Self-pay|7.69||||7.69|1.54|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.69||||7.69|2.99|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.69||||7.69||5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.69||||7.69||5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.69||||7.69||5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.69||||7.69|5.31|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.69||||7.69|0|5.84|1.54
26817|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.69||||7.69||5.84|1.54
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AARP [1000]|AARP [100000]|23||||23||17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AETNA [1015]|AETNA [101529]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMBETTER [2930]|AMBETTER [293000]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23||||23|11.5|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|16.56|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|11.5|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|11.5|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23||||23|17.48|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|CIGNA [1260]|CIGNA PPO [126025]|23||||23|9.2|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23||||23||17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23||||23|11.5|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|Self-pay|Self-pay|23||||23|4.6|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|TML [1980]|TML [198000]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23|8.95|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23||17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UNICARE [2040]|UNICARE [204000]|23||||23||17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23||17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WEB TPA [2115]|WEB TPA [211500]|23||||23|15.87|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23|0|17.48|4.6
27010002|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER NEBLIZR VALVED T-PIECE|1|WORKER'S COMP [2125]|TML WC [212537]|23||||23||17.48|4.6
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AARP [1000]|AARP [100000]|167||||167||126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AETNA [1015]|AETNA [101529]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AMBETTER [2930]|AMBETTER [293000]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|167||||167|83.5|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|167||||167|120.24|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|167||||167|83.5|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|167||||167|83.5|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|167||||167|126.92|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|CIGNA [1260]|CIGNA PPO [126025]|167||||167|66.8|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|167||||167||126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|167||||167|83.5|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|Self-pay|Self-pay|167||||167|33.4|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|TML [1980]|TML [198000]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|167||||167|65|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167||||167||126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|UNICARE [2040]|UNICARE [204000]|167||||167||126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167||||167||126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|WEB TPA [2115]|WEB TPA [211500]|167||||167|115.23|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|167||||167|0|126.92|33.4
27010003|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER OMNI-FLEX|1|WORKER'S COMP [2125]|TML WC [212537]|167||||167||126.92|33.4
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AARP [1000]|AARP [100000]|12.25||||12.25||9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AETNA [1015]|AETNA [101529]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AMBETTER [2930]|AMBETTER [293000]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.25||||12.25|6.13|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.25||||12.25|8.82|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.25||||12.25|6.13|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.25||||12.25|6.13|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.25||||12.25|9.31|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|CIGNA [1260]|CIGNA PPO [126025]|12.25||||12.25|4.9|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.25||||12.25||9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.25||||12.25|6.13|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|Self-pay|Self-pay|12.25||||12.25|2.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|TML [1980]|TML [198000]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.25||||12.25|4.77|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.25||||12.25||9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|UNICARE [2040]|UNICARE [204000]|12.25||||12.25||9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.25||||12.25||9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|WEB TPA [2115]|WEB TPA [211500]|12.25||||12.25|8.45|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.25||||12.25|0|9.31|2.45
27010004|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER RESPIRATORY MONITOR|1|WORKER'S COMP [2125]|TML WC [212537]|12.25||||12.25||9.31|2.45
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AARP [1000]|AARP [100000]|205||||205||155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AETNA [1015]|AETNA [101529]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AMBETTER [2930]|AMBETTER [293000]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205||||205|102.5|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205||||205|147.6|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205||||205|102.5|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205||||205|102.5|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205||||205|155.8|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|CIGNA [1260]|CIGNA PPO [126025]|205||||205|82|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205||||205||155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205||||205|102.5|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|Self-pay|Self-pay|205||||205|41|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|TML [1980]|TML [198000]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205||||205|79.79|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205||||205||155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|UNICARE [2040]|UNICARE [204000]|205||||205||155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205||||205||155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|WEB TPA [2115]|WEB TPA [211500]|205||||205|141.45|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205||||205|0|155.8|41
27010005|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADAPTER VENTILATOR|1|WORKER'S COMP [2125]|TML WC [212537]|205||||205||155.8|41
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AARP [1000]|AARP [100000]|13||||13||9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AETNA [1015]|AETNA [101529]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMBETTER [2930]|AMBETTER [293000]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13||||13|6.5|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13||||13|9.36|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13||||13|6.5|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13||||13|6.5|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13||||13|9.88|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|CIGNA [1260]|CIGNA PPO [126025]|13||||13|5.2|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13||||13||9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13||||13|6.5|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|Self-pay|Self-pay|13||||13|2.6|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|TML [1980]|TML [198000]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13||||13|5.06|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13||||13||9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UNICARE [2040]|UNICARE [204000]|13||||13||9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13||||13||9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WEB TPA [2115]|WEB TPA [211500]|13||||13|8.97|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13||||13|0|9.88|2.6
27010006|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ADULT HIGH FLOW|1|WORKER'S COMP [2125]|TML WC [212537]|13||||13||9.88|2.6
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AARP [1000]|AARP [100000]|85||||85||64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AETNA [1015]|AETNA [101529]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AMBETTER [2930]|AMBETTER [293000]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|85||||85|42.5|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85||||85|61.2|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85||||85|42.5|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85||||85|42.5|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|85||||85|64.6|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|CIGNA [1260]|CIGNA PPO [126025]|85||||85|34|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|85||||85||64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|85||||85|42.5|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|Self-pay|Self-pay|85||||85|17|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|TML [1980]|TML [198000]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85||||85|33.08|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85||||85||64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|UNICARE [2040]|UNICARE [204000]|85||||85||64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85||||85||64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|WEB TPA [2115]|WEB TPA [211500]|85||||85|58.65|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85||||85|0|64.6|17
27010017|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC ANALYZER CO2|1|WORKER'S COMP [2125]|TML WC [212537]|85||||85||64.6|17
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AARP [1000]|AARP [100000]|82||||82||62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AETNA [1015]|AETNA [101529]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AMBETTER [2930]|AMBETTER [293000]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82||||82|41|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|59.04|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|41|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|41|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82||||82|62.32|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|82||||82|32.8|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82||||82||62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82||||82|41|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|Self-pay|Self-pay|82||||82|16.4|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|TML [1980]|TML [198000]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|31.91|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82||62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|UNICARE [2040]|UNICARE [204000]|82||||82||62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82||62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|WEB TPA [2115]|WEB TPA [211500]|82||||82|56.58|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82|0|62.32|16.4
27010021|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG AMBU ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|82||||82||62.32|16.4
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AARP [1000]|AARP [100000]|30||||30||22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AETNA [1015]|AETNA [101529]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AMBETTER [2930]|AMBETTER [293000]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|30||||30|15|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30||||30|21.6|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30||||30|15|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30||||30|15|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|30||||30|22.8|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|CIGNA [1260]|CIGNA PPO [126025]|30||||30|12|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|30||||30||22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|30||||30|15|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|Self-pay|Self-pay|30||||30|6|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|TML [1980]|TML [198000]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30||||30|11.68|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30||||30||22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|UNICARE [2040]|UNICARE [204000]|30||||30||22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30||||30||22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|WEB TPA [2115]|WEB TPA [211500]|30||||30|20.7|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30||||30|0|22.8|6
27010099|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNISTER SUCTION 1500C|1|WORKER'S COMP [2125]|TML WC [212537]|30||||30||22.8|6
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010131|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH SUCTION BALLARD 14F|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AARP [1000]|AARP [100000]|99||||99||75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AETNA [1015]|AETNA [101529]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AMBETTER [2930]|AMBETTER [293000]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99||||99|49.5|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|71.28|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|49.5|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99||||99|75.24|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|CIGNA [1260]|CIGNA PPO [126025]|99||||99|39.6|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99||||99||75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99||||99|49.5|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|Self-pay|Self-pay|99||||99|19.8|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|TML [1980]|TML [198000]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99|38.53|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|UNICARE [2040]|UNICARE [204000]|99||||99||75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|WEB TPA [2115]|WEB TPA [211500]|99||||99|68.31|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99|0|75.24|19.8
27010136|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CHAMBER HUMIDIFIER|1|WORKER'S COMP [2125]|TML WC [212537]|99||||99||75.24|19.8
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AARP [1000]|AARP [100000]|60||||60||45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AETNA [1015]|AETNA [101529]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMBETTER [2930]|AMBETTER [293000]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|60||||60|30|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|43.2|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|30|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|60||||60|45.6|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|CIGNA [1260]|CIGNA PPO [126025]|60||||60|24|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|60||||60||45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|60||||60|30|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|Self-pay|Self-pay|60||||60|12|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|TML [1980]|TML [198000]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60|23.35|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60||45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UNICARE [2040]|UNICARE [204000]|60||||60||45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60||45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WEB TPA [2115]|WEB TPA [211500]|60||||60|41.4|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60|0|45.6|12
27010137|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT BIPAP|1|WORKER'S COMP [2125]|TML WC [212537]|60||||60||45.6|12
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AARP [1000]|AARP [100000]|21||||21||15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AETNA [1015]|AETNA [101529]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AMBETTER [2930]|AMBETTER [293000]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21||||21|10.5|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21||||21|15.12|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21||||21|10.5|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21||||21|10.5|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21||||21|15.96|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|CIGNA [1260]|CIGNA PPO [126025]|21||||21|8.4|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21||||21||15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21||||21|10.5|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|Self-pay|Self-pay|21||||21|4.2|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|TML [1980]|TML [198000]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21||||21|8.17|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21||||21||15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|UNICARE [2040]|UNICARE [204000]|21||||21||15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21||||21||15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|WEB TPA [2115]|WEB TPA [211500]|21||||21|14.49|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21||||21|0|15.96|4.2
27010145|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CIRCUIT VENTILATOR DISP|1|WORKER'S COMP [2125]|TML WC [212537]|21||||21||15.96|4.2
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AARP [1000]|AARP [100000]|85||||85||64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AETNA [1015]|AETNA [101529]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AMBETTER [2930]|AMBETTER [293000]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|85||||85|42.5|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85||||85|61.2|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85||||85|42.5|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85||||85|42.5|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|85||||85|64.6|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|CIGNA [1260]|CIGNA PPO [126025]|85||||85|34|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|85||||85||64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|85||||85|42.5|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|Self-pay|Self-pay|85||||85|17|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|TML [1980]|TML [198000]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85||||85|33.08|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85||||85||64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|UNICARE [2040]|UNICARE [204000]|85||||85||64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85||||85||64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|WEB TPA [2115]|WEB TPA [211500]|85||||85|58.65|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85||||85|0|64.6|17
27010150|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CO2 DETECTOR EASY CAP|1|WORKER'S COMP [2125]|TML WC [212537]|85||||85||64.6|17
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AARP [1000]|AARP [100000]|27||||27||20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA [1015]|AETNA [101529]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMBETTER [2930]|AMBETTER [293000]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27||||27|13.5|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27||||27|10.51|20.52|5.4
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|0|20.52|5.4
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|19.44|20.52|5.4
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|20.52|5.4
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|13.5|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27||||27|20.52|20.52|5.4
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|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27||||27|18.63|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA [1260]|CIGNA PPO [126025]|27||||27|10.8|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27||||27||20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27||||27|13.5|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27||||27|18.63|20.52|5.4
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|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|0|20.52|5.4
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|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|Self-pay|Self-pay|27||||27|5.4|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|TML [1980]|TML [198000]|27||||27|18.63|20.52|5.4
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|10.51|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27||20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNICARE [2040]|UNICARE [204000]|27||||27||20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27||20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WEB TPA [2115]|WEB TPA [211500]|27||||27|18.63|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27|0|20.52|5.4
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|0|20.52|5.4
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WORKER'S COMP [2125]|TML WC [212537]|27||||27||20.52|5.4
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AARP [1000]|AARP [100000]|147.25||||147.25||111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AETNA [1015]|AETNA [101529]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AMBETTER [2930]|AMBETTER [293000]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|147.25||||147.25|73.63|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|147.25||||147.25|106.02|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|147.25||||147.25|73.63|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|147.25||||147.25|73.63|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|147.25||||147.25|111.91|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|CIGNA [1260]|CIGNA PPO [126025]|147.25||||147.25|58.9|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|147.25||||147.25||111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|147.25||||147.25|73.63|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|Self-pay|Self-pay|147.25||||147.25|29.45|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|TML [1980]|TML [198000]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|147.25||||147.25|57.31|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|147.25||||147.25||111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|UNICARE [2040]|UNICARE [204000]|147.25||||147.25||111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|147.25||||147.25||111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|WEB TPA [2115]|WEB TPA [211500]|147.25||||147.25|101.6|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|147.25||||147.25|0|111.91|29.45
27010182|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EZPAP W/DISP MANOMETER|1|WORKER'S COMP [2125]|TML WC [212537]|147.25||||147.25||111.91|29.45
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010186|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AARP [1000]|AARP [100000]|27||||27||20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AETNA [1015]|AETNA [101529]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AMBETTER [2930]|AMBETTER [293000]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27||||27|13.5|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27||||27|19.44|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27||||27|13.5|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27||||27|13.5|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27||||27|20.52|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|CIGNA [1260]|CIGNA PPO [126025]|27||||27|10.8|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27||||27||20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27||||27|13.5|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|Self-pay|Self-pay|27||||27|5.4|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|TML [1980]|TML [198000]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27||||27|10.51|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27||20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|UNICARE [2040]|UNICARE [204000]|27||||27||20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27||20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|WEB TPA [2115]|WEB TPA [211500]|27||||27|18.63|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27||||27|0|20.52|5.4
27010236|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC HUMIDIFIER EXCHANGER|1|WORKER'S COMP [2125]|TML WC [212537]|27||||27||20.52|5.4
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010266|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT TUBING RESPIRATORY|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010277|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK AEROSOL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AARP [1000]|AARP [100000]|209||||209||158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AETNA [1015]|AETNA [101529]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMBETTER [2930]|AMBETTER [293000]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209||||209|104.5|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|150.48|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|104.5|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|104.5|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209||||209|158.84|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|CIGNA [1260]|CIGNA PPO [126025]|209||||209|83.6|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209||||209||158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209||||209|104.5|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|Self-pay|Self-pay|209||||209|41.8|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|TML [1980]|TML [198000]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|81.34|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209||158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UNICARE [2040]|UNICARE [204000]|209||||209||158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209||158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WEB TPA [2115]|WEB TPA [211500]|209||||209|144.21|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209|0|158.84|41.8
27010285|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK CPAP FULL FACE MED|1|WORKER'S COMP [2125]|TML WC [212537]|209||||209||158.84|41.8
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AARP [1000]|AARP [100000]|13||||13||9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AETNA [1015]|AETNA [101529]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMBETTER [2930]|AMBETTER [293000]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13||||13|6.5|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13||||13|9.36|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13||||13|6.5|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13||||13|6.5|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13||||13|9.88|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|CIGNA [1260]|CIGNA PPO [126025]|13||||13|5.2|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13||||13||9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13||||13|6.5|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|Self-pay|Self-pay|13||||13|2.6|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|TML [1980]|TML [198000]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13||||13|5.06|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13||||13||9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UNICARE [2040]|UNICARE [204000]|13||||13||9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13||||13||9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WEB TPA [2115]|WEB TPA [211500]|13||||13|8.97|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13||||13|0|9.88|2.6
27010291|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK NONREBREATHING|1|WORKER'S COMP [2125]|TML WC [212537]|13||||13||9.88|2.6
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010293|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK OXYGEN|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010299|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MASK TRACHEOSTOMY|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AARP [1000]|AARP [100000]|39||||39||29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AETNA [1015]|AETNA [101529]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMBETTER [2930]|AMBETTER [293000]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39||||39|19.5|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39||||39|28.08|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39||||39|19.5|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39||||39|19.5|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39||||39|29.64|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|CIGNA [1260]|CIGNA PPO [126025]|39||||39|15.6|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39||||39||29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39||||39|19.5|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|Self-pay|Self-pay|39||||39|7.8|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|TML [1980]|TML [198000]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39||||39|15.18|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39||||39||29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UNICARE [2040]|UNICARE [204000]|39||||39||29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39||||39||29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WEB TPA [2115]|WEB TPA [211500]|39||||39|26.91|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39||||39|0|29.64|7.8
27010308|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC MDI SPACERS|1|WORKER'S COMP [2125]|TML WC [212537]|39||||39||29.64|7.8
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AARP [1000]|AARP [100000]|300||||300||228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA [1015]|AETNA [101529]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMBETTER [2930]|AMBETTER [293000]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|300||||300|150|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|216|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|150|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|300||||300|228|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA [1260]|CIGNA PPO [126025]|300||||300|120|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|300||||300||228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|300||||300|150|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|Self-pay|Self-pay|300||||300|60|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|TML [1980]|TML [198000]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|116.76|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300||228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNICARE [2040]|UNICARE [204000]|300||||300||228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300||228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WEB TPA [2115]|WEB TPA [211500]|300||||300|207|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300|0|228|60
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WORKER'S COMP [2125]|TML WC [212537]|300||||300||228|60
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AARP [1000]|AARP [100000]|155||||155||117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AETNA [1015]|AETNA [101529]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AMBETTER [2930]|AMBETTER [293000]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|155||||155|77.5|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155||||155|111.6|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155||||155|77.5|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155||||155|77.5|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|155||||155|117.8|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|CIGNA [1260]|CIGNA PPO [126025]|155||||155|62|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|155||||155||117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|155||||155|77.5|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|Self-pay|Self-pay|155||||155|31|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|TML [1980]|TML [198000]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155||||155|60.33|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155||||155||117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|UNICARE [2040]|UNICARE [204000]|155||||155||117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155||||155||117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|WEB TPA [2115]|WEB TPA [211500]|155||||155|106.95|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155||||155|0|117.8|31
27010381|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING AEROSOL CORRUG|1|WORKER'S COMP [2125]|TML WC [212537]|155||||155||117.8|31
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AARP [1000]|AARP [100000]|265||||265||201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AETNA [1015]|AETNA [101529]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMBETTER [2930]|AMBETTER [293000]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|265||||265|132.5|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|265||||265|190.8|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|265||||265|132.5|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|265||||265|132.5|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|265||||265|201.4|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|CIGNA [1260]|CIGNA PPO [126025]|265||||265|106|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|265||||265||201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|265||||265|132.5|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|Self-pay|Self-pay|265||||265|53|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|TML [1980]|TML [198000]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|265||||265|103.14|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|265||||265||201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UNICARE [2040]|UNICARE [204000]|265||||265||201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|265||||265||201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WEB TPA [2115]|WEB TPA [211500]|265||||265|182.85|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|265||||265|0|201.4|53
27010385|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VENT CIRCUIT|1|WORKER'S COMP [2125]|TML WC [212537]|265||||265||201.4|53
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AARP [1000]|AARP [100000]|93||||93||70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AETNA [1015]|AETNA [101529]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|66.96|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|46.5|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|70.68|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|37.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93||70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|Self-pay|Self-pay|93||||93|18.6|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|TML [1980]|TML [198000]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|36.2|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93||70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|UNICARE [2040]|UNICARE [204000]|93||||93||70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93||70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|0|70.68|18.6
27010389|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE ADULT REC|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AARP [1000]|AARP [100000]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AETNA [1015]|AETNA [101529]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|46.5|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|66.96|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|46.5|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|70.68|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|37.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|46.5|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|Self-pay|Self-pay|93||||93|18.6|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|TML [1980]|TML [198000]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|36.2|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|UNICARE [2040]|UNICARE [204000]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93||70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|0|70.68|18.6
27010390|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SENSOR PULSE OX INFANT|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93||70.68|18.6
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010394|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC FILTER BACTERIAL VIRAL MAIN FLOW|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AARP [1000]|AARP [100000]|23||||23||17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AETNA [1015]|AETNA [101529]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AMBETTER [2930]|AMBETTER [293000]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23||||23|11.5|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|16.56|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|11.5|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|11.5|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23||||23|17.48|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|CIGNA [1260]|CIGNA PPO [126025]|23||||23|9.2|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23||||23||17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23||||23|11.5|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|Self-pay|Self-pay|23||||23|4.6|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|TML [1980]|TML [198000]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23|8.95|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23||17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|UNICARE [2040]|UNICARE [204000]|23||||23||17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23||17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|WEB TPA [2115]|WEB TPA [211500]|23||||23|15.87|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23|0|17.48|4.6
27010407|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SPIROMETER INCENTIVE|1|WORKER'S COMP [2125]|TML WC [212537]|23||||23||17.48|4.6
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AARP [1000]|AARP [100000]|64||||64||48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AETNA [1015]|AETNA [101529]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AMBETTER [2930]|AMBETTER [293000]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64||||64|32|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|46.08|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|32|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64||||64|48.64|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|CIGNA [1260]|CIGNA PPO [126025]|64||||64|25.6|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64||||64||48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64||||64|32|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|Self-pay|Self-pay|64||||64|12.8|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|TML [1980]|TML [198000]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64|24.91|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64||48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|UNICARE [2040]|UNICARE [204000]|64||||64||48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64||48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|WEB TPA [2115]|WEB TPA [211500]|64||||64|44.16|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64|0|48.64|12.8
27010490|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUCTION CLOSED 14FR|1|WORKER'S COMP [2125]|TML WC [212537]|64||||64||48.64|12.8
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AARP [1000]|AARP [100000]|48||||48||36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AETNA [1015]|AETNA [101529]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AMBETTER [2930]|AMBETTER [293000]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48||||48|24|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48||||48|34.56|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48||||48|24|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48||||48|24|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48||||48|36.48|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|CIGNA [1260]|CIGNA PPO [126025]|48||||48|19.2|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48||||48||36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48||||48|24|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|Self-pay|Self-pay|48||||48|9.6|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|TML [1980]|TML [198000]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48||||48|18.68|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48||||48||36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|UNICARE [2040]|UNICARE [204000]|48||||48||36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48||||48||36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|WEB TPA [2115]|WEB TPA [211500]|48||||48|33.12|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48||||48|0|36.48|9.6
27010494|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SUPPLIES SET UP AEROSOL|1|WORKER'S COMP [2125]|TML WC [212537]|48||||48||36.48|9.6
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AARP [1000]|AARP [100000]|667||||667||506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AETNA [1015]|AETNA [101529]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMBETTER [2930]|AMBETTER [293000]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|667||||667|333.5|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|667||||667|480.24|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|667||||667|333.5|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|667||||667|333.5|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|667||||667|506.92|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|CIGNA [1260]|CIGNA PPO [126025]|667||||667|266.8|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|667||||667||506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|667||||667|333.5|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|Self-pay|Self-pay|667||||667|133.4|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|TML [1980]|TML [198000]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|667||||667|259.6|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|667||||667||506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UNICARE [2040]|UNICARE [204000]|667||||667||506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|667||||667||506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WEB TPA [2115]|WEB TPA [211500]|667||||667|460.23|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|667||||667|0|506.92|133.4
27010513|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VAPOTHERM CIRCUIT|1|WORKER'S COMP [2125]|TML WC [212537]|667||||667||506.92|133.4
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AARP [1000]|AARP [100000]|585.5||||585.5||444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AETNA [1015]|AETNA [101529]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AMBETTER [2930]|AMBETTER [293000]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|585.5||||585.5|292.75|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|585.5||||585.5|421.56|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|585.5||||585.5|292.75|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|585.5||||585.5|292.75|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|585.5||||585.5|444.98|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|CIGNA [1260]|CIGNA PPO [126025]|585.5||||585.5|234.2|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|585.5||||585.5||444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|585.5||||585.5|292.75|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|Self-pay|Self-pay|585.5||||585.5|117.1|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|TML [1980]|TML [198000]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|585.5||||585.5|227.88|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|585.5||||585.5||444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|UNICARE [2040]|UNICARE [204000]|585.5||||585.5||444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|585.5||||585.5||444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|WEB TPA [2115]|WEB TPA [211500]|585.5||||585.5|404|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|585.5||||585.5|0|444.98|117.1
27010514|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC VEST VIBRATORY DISP|1|WORKER'S COMP [2125]|TML WC [212537]|585.5||||585.5||444.98|117.1
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AQUAPAK WATER|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010591|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC SYRINGE BLD GAS KIT W/HE|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AARP [1000]|AARP [100000]|103.75||||103.75||78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AETNA [1015]|AETNA [101529]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AMBETTER [2930]|AMBETTER [293000]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103.75||||103.75|51.88|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103.75||||103.75|74.7|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103.75||||103.75|51.88|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103.75||||103.75|51.88|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103.75||||103.75|78.85|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|CIGNA [1260]|CIGNA PPO [126025]|103.75||||103.75|41.5|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103.75||||103.75||78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103.75||||103.75|51.88|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|Self-pay|Self-pay|103.75||||103.75|20.75|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|TML [1980]|TML [198000]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103.75||||103.75|40.38|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103.75||||103.75||78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|UNICARE [2040]|UNICARE [204000]|103.75||||103.75||78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103.75||||103.75||78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|WEB TPA [2115]|WEB TPA [211500]|103.75||||103.75|71.59|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103.75||||103.75|0|78.85|20.75
27010594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER ADULT MONITOR|1|WORKER'S COMP [2125]|TML WC [212537]|103.75||||103.75||78.85|20.75
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AARP [1000]|AARP [100000]|146||||146||110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AETNA [1015]|AETNA [101529]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AMBETTER [2930]|AMBETTER [293000]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|73|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|105.12|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|73|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|110.96|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|58.4|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146||110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|73|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|Self-pay|Self-pay|146||||146|29.2|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|TML [1980]|TML [198000]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|56.82|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|UNICARE [2040]|UNICARE [204000]|146||||146||110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146|0|110.96|29.2
27010610|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC METERED DOSE INHALER SPACERONL|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146||110.96|29.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27010636|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER HUDSON HAND HELD|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.82||||2.82||2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.82||||2.82|1.41|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.82||||2.82|2.03|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.82||||2.82|1.41|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.82||||2.82|1.41|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.82||||2.82|2.14|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.82||||2.82|1.13|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.82||||2.82||2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.82||||2.82|1.41|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.82||||2.82|0.56|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.82||||2.82|1.1|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.82||||2.82||2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.82||||2.82||2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.82||||2.82||2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.82||||2.82|1.95|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.82||||2.82|0|2.14|0.56
27094|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE MICRONIZED 134 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.82||||2.82||2.14|0.56
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AARP [1000]|AARP [100000]|2469.23||||2469.23||1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AETNA [1015]|AETNA [101529]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AMBETTER [2930]|AMBETTER [293000]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2469.23||||2469.23|1234.62|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2469.23||||2469.23|1777.85|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2469.23||||2469.23|1234.62|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2469.23||||2469.23|1234.62|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2469.23||||2469.23|1876.61|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|CIGNA [1260]|CIGNA PPO [126025]|2469.23||||2469.23|987.69|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2469.23||||2469.23||1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|GROUP PENSION ADMIN [1450]|GPA [145000]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2469.23||||2469.23|1234.62|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|PHCS [1780]|PHCS MULTIPLAN [178000]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|Self-pay|Self-pay|2469.23||||2469.23|493.85|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|TML [1980]|TML [198000]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2469.23||||2469.23|961.02|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2469.23||||2469.23||1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|UNICARE [2040]|UNICARE [204000]|2469.23||||2469.23||1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2469.23||||2469.23||1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|WEB TPA [2115]|WEB TPA [211500]|2469.23||||2469.23|1703.77|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2469.23||||2469.23|0|1876.61|493.85
27096|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL|4.9 g|WORKER'S COMP [2125]|TML WC [212537]|2469.23||||2469.23||1876.61|493.85
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AARP [1000]|AARP [100000]|34||||34||25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AETNA [1015]|AETNA [101529]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AMBETTER [2930]|AMBETTER [293000]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34||||34|17|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|24.48|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|17|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34||||34|25.84|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|34||||34|13.6|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34||||34||25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34||||34|17|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|Self-pay|Self-pay|34||||34|6.8|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|TML [1980]|TML [198000]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|13.23|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|UNICARE [2040]|UNICARE [204000]|34||||34||25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|WEB TPA [2115]|WEB TPA [211500]|34||||34|23.46|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34|0|25.84|6.8
27100015|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC INITIAL ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AARP [1000]|AARP [100000]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AETNA [1015]|AETNA [101529]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AMBETTER [2930]|AMBETTER [293000]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34||||34|17|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|24.48|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|17|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34||||34|25.84|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|34||||34|13.6|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34||||34|17|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|Self-pay|Self-pay|34||||34|6.8|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|TML [1980]|TML [198000]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|13.23|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|UNICARE [2040]|UNICARE [204000]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|WEB TPA [2115]|WEB TPA [211500]|34||||34|23.46|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34|0|25.84|6.8
27100017|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC HFNC SUBSEQUENT ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|34||||34||25.84|6.8
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AARP [1000]|AARP [100000]|108||||108||82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AETNA [1015]|AETNA [101529]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AMBETTER [2930]|AMBETTER [293000]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|108||||108|54|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108||||108|77.76|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108||||108|54|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108||||108|54|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|108||||108|82.08|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|CIGNA [1260]|CIGNA PPO [126025]|108||||108|43.2|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|108||||108||82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|108||||108|54|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|Self-pay|Self-pay|108||||108|21.6|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|TML [1980]|TML [198000]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108||||108|42.03|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108||||108||82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|UNICARE [2040]|UNICARE [204000]|108||||108||82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108||||108||82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|WEB TPA [2115]|WEB TPA [211500]|108||||108|74.52|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108||||108|0|82.08|21.6
27210052|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC BIPAP MASK FULL FACE|1|WORKER'S COMP [2125]|TML WC [212537]|108||||108||82.08|21.6
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AARP [1000]|AARP [100000]|34||||34||25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AETNA [1015]|AETNA [101529]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AMBETTER [2930]|AMBETTER [293000]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34||||34|17|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|24.48|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|17|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34||||34|25.84|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|34||||34|13.6|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34||||34||25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34||||34|17|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|Self-pay|Self-pay|34||||34|6.8|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|TML [1980]|TML [198000]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|13.23|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|UNICARE [2040]|UNICARE [204000]|34||||34||25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|WEB TPA [2115]|WEB TPA [211500]|34||||34|23.46|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34|0|25.84|6.8
27210086|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA HIGH FLOW PED/ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|34||||34||25.84|6.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AARP [1000]|AARP [100000]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AETNA [1015]|AETNA [101529]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMBETTER [2930]|AMBETTER [293000]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184|132.48|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184||||184|139.84|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|CIGNA [1260]|CIGNA PPO [126025]|184||||184|73.6|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|Self-pay|Self-pay|184||||184|36.8|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|TML [1980]|TML [198000]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|71.61|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UNICARE [2040]|UNICARE [204000]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184|92|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WEB TPA [2115]|WEB TPA [211500]|184||||184|126.96|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184|0|139.84|36.8
27210090|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CANNULA NASAL AIRVO OPT844 RT|1|WORKER'S COMP [2125]|TML WC [212537]|184||||184|92|139.84|36.8
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210096|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA OXYGEN NASAL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AARP [1000]|AARP [100000]|85||||85||64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AETNA [1015]|AETNA [101529]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AMBETTER [2930]|AMBETTER [293000]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|85||||85|42.5|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85||||85|61.2|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85||||85|42.5|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85||||85|42.5|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|85||||85|64.6|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|CIGNA [1260]|CIGNA PPO [126025]|85||||85|34|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|85||||85||64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|85||||85|42.5|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|Self-pay|Self-pay|85||||85|17|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|TML [1980]|TML [198000]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85||||85|33.08|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85||||85||64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|UNICARE [2040]|UNICARE [204000]|85||||85||64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85||||85||64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|WEB TPA [2115]|WEB TPA [211500]|85||||85|58.65|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85||||85|0|64.6|17
27210101|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CAP DETECTOR CO2 NELLCOR|1|WORKER'S COMP [2125]|TML WC [212537]|85||||85||64.6|17
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AARP [1000]|AARP [100000]|264||||264||200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AETNA [1015]|AETNA [101529]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMBETTER [2930]|AMBETTER [293000]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|132|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|190.08|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|132|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|200.64|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264||200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|132|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|Self-pay|Self-pay|264||||264|52.8|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|TML [1980]|TML [198000]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|102.75|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UNICARE [2040]|UNICARE [204000]|264||||264||200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264|0|200.64|52.8
27210232|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC CIRCUIT AIRVO HEATED 900PT501|1|WORKER'S COMP [2125]|TML WC [212537]|264||||264||200.64|52.8
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AARP [1000]|AARP [100000]|80||||80||60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AETNA [1015]|AETNA [101529]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AMBETTER [2930]|AMBETTER [293000]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80||||80|40|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80||||80|57.6|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80||||80|40|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80||||80|40|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80||||80|60.8|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|CIGNA [1260]|CIGNA PPO [126025]|80||||80|32|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80||||80||60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80||||80|40|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|Self-pay|Self-pay|80||||80|16|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|TML [1980]|TML [198000]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80||||80|31.14|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80||||80||60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|UNICARE [2040]|UNICARE [204000]|80||||80||60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80||||80||60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|WEB TPA [2115]|WEB TPA [211500]|80||||80|55.2|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80||||80|0|60.8|16
27210441|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC FASTNER TUBE ORAL ENDOTRACHEAL|1|WORKER'S COMP [2125]|TML WC [212537]|80||||80||60.8|16
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AARP [1000]|AARP [100000]|25||||25||19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AETNA [1015]|AETNA [101529]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMBETTER [2930]|AMBETTER [293000]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25||||25|12.5|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|18|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|12.5|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25||||25|19|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|CIGNA [1260]|CIGNA PPO [126025]|25||||25|10|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25||||25||19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25||||25|12.5|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|Self-pay|Self-pay|25||||25|5|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|TML [1980]|TML [198000]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|9.73|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25||19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UNICARE [2040]|UNICARE [204000]|25||||25||19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25||19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WEB TPA [2115]|WEB TPA [211500]|25||||25|17.25|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25|0|19|5
27210519|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HIGH FLO BUBBLER|1|WORKER'S COMP [2125]|TML WC [212537]|25||||25||19|5
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AARP [1000]|AARP [100000]|99||||99||75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AETNA [1015]|AETNA [101529]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AMBETTER [2930]|AMBETTER [293000]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99||||99|49.5|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|71.28|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|49.5|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99||||99|75.24|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|CIGNA [1260]|CIGNA PPO [126025]|99||||99|39.6|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99||||99||75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99||||99|49.5|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|Self-pay|Self-pay|99||||99|19.8|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|TML [1980]|TML [198000]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99|38.53|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|UNICARE [2040]|UNICARE [204000]|99||||99||75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|WEB TPA [2115]|WEB TPA [211500]|99||||99|68.31|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99|0|75.24|19.8
27210521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC HUMIDIFIER CHAMBER|1|WORKER'S COMP [2125]|TML WC [212537]|99||||99||75.24|19.8
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AARP [1000]|AARP [100000]|146||||146||110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AETNA [1015]|AETNA [101529]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AMBETTER [2930]|AMBETTER [293000]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|73|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|105.12|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|73|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|110.96|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|58.4|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146||110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|73|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|Self-pay|Self-pay|146||||146|29.2|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|TML [1980]|TML [198000]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|56.82|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|UNICARE [2040]|UNICARE [204000]|146||||146||110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146|0|110.96|29.2
27210525|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC INHALER AEROSOL|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146||110.96|29.2
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AARP [1000]|AARP [100000]|134||||134||101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AETNA [1015]|AETNA [101529]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMBETTER [2930]|AMBETTER [293000]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|134||||134|67|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134||||134|96.48|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134||||134|67|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134||||134|67|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|134||||134|101.84|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|CIGNA [1260]|CIGNA PPO [126025]|134||||134|53.6|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|134||||134||101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|134||||134|67|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|Self-pay|Self-pay|134||||134|26.8|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|TML [1980]|TML [198000]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134||||134|52.15|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134||||134||101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UNICARE [2040]|UNICARE [204000]|134||||134||101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134||||134||101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WEB TPA [2115]|WEB TPA [211500]|134||||134|92.46|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134||||134|0|101.84|26.8
27210540|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IV SET BLOOD SOL Y-TYPE|1|WORKER'S COMP [2125]|TML WC [212537]|134||||134||101.84|26.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AARP [1000]|AARP [100000]|64||||64||48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AETNA [1015]|AETNA [101529]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AMBETTER [2930]|AMBETTER [293000]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64||||64|32|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|46.08|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|32|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64||||64|48.64|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|CIGNA [1260]|CIGNA PPO [126025]|64||||64|25.6|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64||||64||48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64||||64|32|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|Self-pay|Self-pay|64||||64|12.8|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|TML [1980]|TML [198000]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64|24.91|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64||48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|UNICARE [2040]|UNICARE [204000]|64||||64||48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64||48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|WEB TPA [2115]|WEB TPA [211500]|64||||64|44.16|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64|0|48.64|12.8
27210594|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC KIT SUCTION CLOSED SYSTE|1|WORKER'S COMP [2125]|TML WC [212537]|64||||64||48.64|12.8
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210629|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC MASK VENTURI|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210692|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER CONTINUOUS|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210693|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC NEBULIZER DISP|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AARP [1000]|AARP [100000]|34||||34||25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AETNA [1015]|AETNA [101529]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AMBETTER [2930]|AMBETTER [293000]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34||||34|17|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|24.48|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|17|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34||||34|25.84|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|34||||34|13.6|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34||||34||25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34||||34|17|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|Self-pay|Self-pay|34||||34|6.8|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|TML [1980]|TML [198000]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|13.23|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|UNICARE [2040]|UNICARE [204000]|34||||34||25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|WEB TPA [2115]|WEB TPA [211500]|34||||34|23.46|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34|0|25.84|6.8
27210725|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OPTIFLOW CANNULA ALL SIZES ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|34||||34||25.84|6.8
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AARP [1000]|AARP [100000]|72||||72||54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AETNA [1015]|AETNA [101529]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AMBETTER [2930]|AMBETTER [293000]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72||||72|36|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|51.84|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|36|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|72||||72|54.72|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|CIGNA [1260]|CIGNA PPO [126025]|72||||72|28.8|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72||||72||54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72||||72|36|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|Self-pay|Self-pay|72||||72|14.4|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|TML [1980]|TML [198000]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|28.02|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72||54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|UNICARE [2040]|UNICARE [204000]|72||||72||54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72||54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|WEB TPA [2115]|WEB TPA [211500]|72||||72|49.68|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72|0|54.72|14.4
27210736|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXIMAX FOREHEAD OXIMETRY MAXFA|1|WORKER'S COMP [2125]|TML WC [212537]|72||||72||54.72|14.4
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210737|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC OXYGEN BUBBLE HUMIDIFIER|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AARP [1000]|AARP [100000]|83||||83||63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AETNA [1015]|AETNA [101529]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AMBETTER [2930]|AMBETTER [293000]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83||||83|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83||||83|41.5|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83||||83|32.3|63.08|16.6
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|0|63.08|16.6
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|59.76|63.08|16.6
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|63.08|16.6
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|41.5|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83||||83|63.08|63.08|16.6
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|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83||||83|57.27|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA [1260]|CIGNA PPO [126025]|83||||83|33.2|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83||||83||63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|83||||83|57.27|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83||||83|41.5|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83||||83|57.27|63.08|16.6
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|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83||||83|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83||||83|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83||||83|0|63.08|16.6
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|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|83||||83|57.27|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83||||83|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|Self-pay|Self-pay|83||||83|16.6|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|TML [1980]|TML [198000]|83||||83|57.27|63.08|16.6
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|32.3|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83||||83||63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UNICARE [2040]|UNICARE [204000]|83||||83||63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83||||83||63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|WEB TPA [2115]|WEB TPA [211500]|83||||83|57.27|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83||||83|0|63.08|16.6
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|0|63.08|16.6
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|WORKER'S COMP [2125]|TML WC [212537]|83||||83||63.08|16.6
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AARP [1000]|AARP [100000]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNICARE [2040]|UNICARE [204000]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11|5.5|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11|5.5|8.36|2.2
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AARP [1000]|AARP [100000]|33||||33||25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AETNA [1015]|AETNA [101529]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|23.76|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|16.5|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33||25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|Self-pay|Self-pay|33||||33|6.6|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|TML [1980]|TML [198000]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|12.84|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33||25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|UNICARE [2040]|UNICARE [204000]|33||||33||25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33||25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33|0|25.08|6.6
27210841|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SUCTION WATER STERILE 4O|1|WORKER'S COMP [2125]|TML WC [212537]|33||||33||25.08|6.6
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AARP [1000]|AARP [100000]|62||||62||47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AETNA [1015]|AETNA [101529]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AMBETTER [2930]|AMBETTER [293000]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62||||62|31|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62||||62|44.64|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62||||62|31|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62||||62|31|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62||||62|47.12|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|CIGNA [1260]|CIGNA PPO [126025]|62||||62|24.8|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62||||62||47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|GROUP PENSION ADMIN [1450]|GPA [145000]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62||||62|31|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|PHCS [1780]|PHCS MULTIPLAN [178000]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|Self-pay|Self-pay|62||||62|12.4|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|TML [1980]|TML [198000]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62||||62|24.13|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62||||62||47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|UNICARE [2040]|UNICARE [204000]|62||||62||47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62||||62||47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|WEB TPA [2115]|WEB TPA [211500]|62||||62|42.78|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62||||62|0|47.12|12.4
27210880|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SOLUTION IRRIG ST WATER 1000ML|1|WORKER'S COMP [2125]|TML WC [212537]|62||||62||47.12|12.4
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AARP [1000]|AARP [100000]|13.25||||13.25||10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AETNA [1015]|AETNA [101529]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AMBETTER [2930]|AMBETTER [293000]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.25||||13.25|6.63|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.25||||13.25|9.54|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.25||||13.25|6.63|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.25||||13.25|6.63|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.25||||13.25|10.07|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|CIGNA [1260]|CIGNA PPO [126025]|13.25||||13.25|5.3|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.25||||13.25||10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.25||||13.25|6.63|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|Self-pay|Self-pay|13.25||||13.25|2.65|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|TML [1980]|TML [198000]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.25||||13.25|5.16|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.25||||13.25||10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|UNICARE [2040]|UNICARE [204000]|13.25||||13.25||10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.25||||13.25||10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|WEB TPA [2115]|WEB TPA [211500]|13.25||||13.25|9.14|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.25||||13.25|0|10.07|2.65
27210918|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC STYLET INTUBATING|1|WORKER'S COMP [2125]|TML WC [212537]|13.25||||13.25||10.07|2.65
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AARP [1000]|AARP [100000]|18||||18||13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AETNA [1015]|AETNA [101529]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AMBETTER [2930]|AMBETTER [293000]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18||||18|9|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18||||18|12.96|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18||||18|9|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18||||18|9|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18||||18|13.68|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|CIGNA [1260]|CIGNA PPO [126025]|18||||18|7.2|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18||||18||13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18||||18|9|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|Self-pay|Self-pay|18||||18|3.6|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|TML [1980]|TML [198000]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18||||18|7.01|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18||||18||13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|UNICARE [2040]|UNICARE [204000]|18||||18||13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18||||18||13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|WEB TPA [2115]|WEB TPA [211500]|18||||18|12.42|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18||||18|0|13.68|3.6
27210919|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STYLET INTUBATING 14 FR|1|WORKER'S COMP [2125]|TML WC [212537]|18||||18||13.68|3.6
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AARP [1000]|AARP [100000]|72||||72||54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AETNA [1015]|AETNA [101529]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AMBETTER [2930]|AMBETTER [293000]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|72||||72|36|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|51.84|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|36|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|72||||72|54.72|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|72||||72|28.8|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|72||||72||54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|72||||72|36|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|Self-pay|Self-pay|72||||72|14.4|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|TML [1980]|TML [198000]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|28.02|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72||54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|UNICARE [2040]|UNICARE [204000]|72||||72||54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72||54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|WEB TPA [2115]|WEB TPA [211500]|72||||72|49.68|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72|0|54.72|14.4
27211039|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|72||||72||54.72|14.4
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AARP [1000]|AARP [100000]|104||||104||79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AETNA [1015]|AETNA [101529]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|52|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|74.88|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|52|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|79.04|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|41.6|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104||79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|52|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|Self-pay|Self-pay|104||||104|20.8|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|TML [1980]|TML [198000]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|40.48|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104||79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|UNICARE [2040]|UNICARE [204000]|104||||104||79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104||79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|0|79.04|20.8
27211040|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRANSDUCER OXISENSOR INFANT|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104||79.04|20.8
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AARP [1000]|AARP [100000]|26||||26||19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AETNA [1015]|AETNA [101529]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AMBETTER [2930]|AMBETTER [293000]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26||||26|13|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26||||26|18.72|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26||||26|13|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26||||26|13|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26||||26|19.76|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|CIGNA [1260]|CIGNA PPO [126025]|26||||26|10.4|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26||||26||19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26||||26|13|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|Self-pay|Self-pay|26||||26|5.2|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|TML [1980]|TML [198000]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26||||26|10.12|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26||||26||19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|UNICARE [2040]|UNICARE [204000]|26||||26||19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26||||26||19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|WEB TPA [2115]|WEB TPA [211500]|26||||26|17.94|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26||||26|0|19.76|5.2
27211210|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TRAY TRACHEAL CLEAN AND|1|WORKER'S COMP [2125]|TML WC [212537]|26||||26||19.76|5.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AARP [1000]|AARP [100000]|36||||36||27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AETNA [1015]|AETNA [101529]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AMBETTER [2930]|AMBETTER [293000]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|18|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|25.92|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|18|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|27.36|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|14.4|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|18|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|Self-pay|Self-pay|36||||36|7.2|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|TML [1980]|TML [198000]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36|14.01|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|UNICARE [2040]|UNICARE [204000]|36||||36||27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36|0|27.36|7.2
27211236|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBE ENDOTRACHEAL|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||27.36|7.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27211248|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBE TRACH DISP CUFF SZ6|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AARP [1000]|AARP [100000]|191||||191||145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AETNA [1015]|AETNA [101529]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AMBETTER [2930]|AMBETTER [293000]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|191||||191|89.77|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191||||191|137.52|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191||||191|95.5|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191||||191|95.5|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|191||||191|145.16|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|CIGNA [1260]|CIGNA PPO [126025]|191||||191|76.4|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|191||||191||145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|191||||191|89.77|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|Self-pay|Self-pay|191||||191|38.2|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|TML [1980]|TML [198000]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191||||191|74.34|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191||||191||145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|UNICARE [2040]|UNICARE [204000]|191||||191||145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191||||191||145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|WEB TPA [2115]|WEB TPA [211500]|191||||191|131.79|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191||||191|0|145.16|38.2
27211250|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TUBE TRACHEOSTOMY ADULT|1|WORKER'S COMP [2125]|TML WC [212537]|191||||191||145.16|38.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27211258|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING EXT|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27211264|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC TUBING NASAL CANNULA|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27211273|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONNECTING|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AARP [1000]|AARP [100000]|264||||264||200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AETNA [1015]|AETNA [101529]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AMBETTER [2930]|AMBETTER [293000]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|132|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|190.08|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|132|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|200.64|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264||200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|132|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|Self-pay|Self-pay|264||||264|52.8|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|TML [1980]|TML [198000]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|102.75|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|UNICARE [2040]|UNICARE [204000]|264||||264||200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264|0|200.64|52.8
27211292|EAP|0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-NONST|HC VENTILATOR CIRCUIT EACH|1|WORKER'S COMP [2125]|TML WC [212537]|264||||264||200.64|52.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AARP [1000]|AARP [100000]|64||||64||48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AETNA [1015]|AETNA [101529]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AMBETTER [2930]|AMBETTER [293000]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|64||||64|32|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|46.08|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|32|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|64||||64|48.64|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|CIGNA [1260]|CIGNA PPO [126025]|64||||64|25.6|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|64||||64||48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|64||||64|32|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|Self-pay|Self-pay|64||||64|12.8|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|TML [1980]|TML [198000]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64|24.91|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64||48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|UNICARE [2040]|UNICARE [204000]|64||||64||48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64||48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|WEB TPA [2115]|WEB TPA [211500]|64||||64|44.16|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64|0|48.64|12.8
27211384|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC KIT TRACH CARE SUCTION|1|WORKER'S COMP [2125]|TML WC [212537]|64||||64||48.64|12.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AARP [1000]|AARP [100000]|29||||29||22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AETNA [1015]|AETNA [101529]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AMBETTER [2930]|AMBETTER [293000]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29||||29|14.5|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|20.88|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|14.5|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29||||29|22.04|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|CIGNA [1260]|CIGNA PPO [126025]|29||||29|11.6|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29||||29||22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29||||29|14.5|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|Self-pay|Self-pay|29||||29|5.8|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|TML [1980]|TML [198000]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29|11.29|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29||22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|UNICARE [2040]|UNICARE [204000]|29||||29||22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29||22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|WEB TPA [2115]|WEB TPA [211500]|29||||29|20.01|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29|0|22.04|5.8
27211425|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC SYRINGE BLOOD GAS KIT 1CC|1|WORKER'S COMP [2125]|TML WC [212537]|29||||29||22.04|5.8
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AARP [1000]|AARP [100000]|616||||616||468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AETNA [1015]|AETNA [101529]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AMBETTER [2930]|AMBETTER [293000]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|616||||616|308|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|616||||616|443.52|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|616||||616|308|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|616||||616|308|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|616||||616|468.16|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|CIGNA [1260]|CIGNA PPO [126025]|616||||616|246.4|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|616||||616||468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|616||||616|308|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|Self-pay|Self-pay|616||||616|123.2|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|TML [1980]|TML [198000]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|616||||616|239.75|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|616||||616||468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|UNICARE [2040]|UNICARE [204000]|616||||616||468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|616||||616||468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|WEB TPA [2115]|WEB TPA [211500]|616||||616|425.04|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|616||||616|0|468.16|123.2
27211521|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC AEROSOL SUBSEQUENT PER DAY|1|WORKER'S COMP [2125]|TML WC [212537]|616||||616||468.16|123.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AARP [1000]|AARP [100000]|36||||36||27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AETNA [1015]|AETNA [101529]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AMBETTER [2930]|AMBETTER [293000]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|18|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|25.92|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|18|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|27.36|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|14.4|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|18|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|Self-pay|Self-pay|36||||36|7.2|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|TML [1980]|TML [198000]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36|14.01|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|UNICARE [2040]|UNICARE [204000]|36||||36||27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36|0|27.36|7.2
27211606|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC ENDOTRACHEAL TUBE|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||27.36|7.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AARP [1000]|AARP [100000]|11||||11||8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AETNA [1015]|AETNA [101529]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|7.92|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|5.5|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|Self-pay|Self-pay|11||||11|2.2|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|4.28|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11|0|8.36|2.2
27211764|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TUBING SUCTION CONCTING 10FT|1|WORKER'S COMP [2125]|TML WC [212537]|11||||11||8.36|2.2
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AARP [1000]|AARP [100000]|77||||77||58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AETNA [1015]|AETNA [101529]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AMBETTER [2930]|AMBETTER [293000]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|77||||77|38.5|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77||||77|55.44|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77||||77|38.5|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77||||77|38.5|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|77||||77|58.52|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|CIGNA [1260]|CIGNA PPO [126025]|77||||77|30.8|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|77||||77||58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|77||||77|38.5|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|Self-pay|Self-pay|77||||77|15.4|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|TML [1980]|TML [198000]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77||||77|29.97|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77||||77||58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|UNICARE [2040]|UNICARE [204000]|77||||77||58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77||||77||58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|WEB TPA [2115]|WEB TPA [211500]|77||||77|53.13|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77||||77|0|58.52|15.4
27211778|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC NEBULIZER SOLO|1|WORKER'S COMP [2125]|TML WC [212537]|77||||77||58.52|15.4
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AARP [1000]|AARP [100000]|154.75||||154.75||117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AETNA [1015]|AETNA [101529]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AMBETTER [2930]|AMBETTER [293000]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|154.75||||154.75|77.38|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154.75||||154.75|111.42|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154.75||||154.75|77.38|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154.75||||154.75|77.38|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|154.75||||154.75|117.61|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|CIGNA [1260]|CIGNA PPO [126025]|154.75||||154.75|61.9|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|154.75||||154.75||117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|154.75||||154.75|77.38|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|Self-pay|Self-pay|154.75||||154.75|30.95|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|TML [1980]|TML [198000]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154.75||||154.75|60.23|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154.75||||154.75||117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|UNICARE [2040]|UNICARE [204000]|154.75||||154.75||117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154.75||||154.75||117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|WEB TPA [2115]|WEB TPA [211500]|154.75||||154.75|106.78|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154.75||||154.75|0|117.61|30.95
27211848|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CIRCUIT T-PIECE SINGLE USE|1|WORKER'S COMP [2125]|TML WC [212537]|154.75||||154.75||117.61|30.95
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AARP [1000]|AARP [100000]|36||||36||27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AETNA [1015]|AETNA [101529]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AMBETTER [2930]|AMBETTER [293000]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|18|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|25.92|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|18|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|27.36|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|14.4|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|18|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|Self-pay|Self-pay|36||||36|7.2|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|TML [1980]|TML [198000]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36|14.01|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|UNICARE [2040]|UNICARE [204000]|36||||36||27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36|0|27.36|7.2
27211941|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRACH TUBE|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||27.36|7.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AARP [1000]|AARP [100000]|171||||171||129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AETNA [1015]|AETNA [101529]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AMBETTER [2930]|AMBETTER [293000]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|171||||171|85.5|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171||||171|123.12|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171||||171|85.5|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171||||171|85.5|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|171||||171|129.96|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|CIGNA [1260]|CIGNA PPO [126025]|171||||171|68.4|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|171||||171||129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|171||||171|85.5|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|Self-pay|Self-pay|171||||171|34.2|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|TML [1980]|TML [198000]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171||||171|66.55|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171||||171||129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|UNICARE [2040]|UNICARE [204000]|171||||171||129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171||||171||129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|WEB TPA [2115]|WEB TPA [211500]|171||||171|117.99|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171||||171|0|129.96|34.2
27211964|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CANNULA INNER DISP TRACH 8 SHILEY|1|WORKER'S COMP [2125]|TML WC [212537]|171||||171||129.96|34.2
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AARP [1000]|AARP [100000]|33||||33||25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AETNA [1015]|AETNA [101529]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|23.76|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|16.5|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33||25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|Self-pay|Self-pay|33||||33|6.6|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|TML [1980]|TML [198000]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|12.84|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33||25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|UNICARE [2040]|UNICARE [204000]|33||||33||25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33||25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33|0|25.08|6.6
27212012|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC IRRIG STERILE WATER 250ML BTL|1|WORKER'S COMP [2125]|TML WC [212537]|33||||33||25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AARP [1000]|AARP [100000]|33||||33||25.08|6.6
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|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AETNA [1015]|AETNA [101529]|33||||33|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|12.84|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|16.5|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|25.08|6.6
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|0|25.08|6.6
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|23.76|25.08|6.6
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|25.08|6.6
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|16.5|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|25.08|6.6
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|12.84|25.08|6.6
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|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33||25.08|6.6
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|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|16.5|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|25.08|6.6
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|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|25.08|6.6
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|12.84|25.08|6.6
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|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|0|25.08|6.6
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|12.84|25.08|6.6
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|25.08|6.6
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|12.84|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|Self-pay|Self-pay|33||||33|6.6|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|TML [1980]|TML [198000]|33||||33|22.77|25.08|6.6
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|12.84|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33||25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNICARE [2040]|UNICARE [204000]|33||||33||25.08|6.6
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||25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|25.08|6.6
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|0|25.08|6.6
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|0|25.08|6.6
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WORKER'S COMP [2125]|TML WC [212537]|33||||33||25.08|6.6
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AARP [1000]|AARP [100000]|719.5||||719.5||546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AETNA [1015]|AETNA [101529]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMBETTER [2930]|AMBETTER [293000]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|719.5||||719.5|338.17|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|719.5||||719.5|518.04|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|719.5||||719.5|359.75|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|719.5||||719.5|359.75|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|719.5||||719.5|546.82|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|CIGNA [1260]|CIGNA PPO [126025]|719.5||||719.5|287.8|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|719.5||||719.5||546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|719.5||||719.5|338.17|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|Self-pay|Self-pay|719.5||||719.5|143.9|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|TML [1980]|TML [198000]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|719.5||||719.5||546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UNICARE [2040]|UNICARE [204000]|719.5||||719.5||546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|719.5||||719.5||546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WEB TPA [2115]|WEB TPA [211500]|719.5||||719.5|496.46|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|719.5||||719.5|0|546.82|143.9
27408501|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC TRACH SPEAKING VALVE|1|WORKER'S COMP [2125]|TML WC [212537]|719.5||||719.5||546.82|143.9
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AARP [1000]|AARP [100000]|83.16||||83.16||63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA [1015]|AETNA [101529]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMBETTER [2930]|AMBETTER [293000]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.16||||83.16|41.58|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.16||||83.16|32.37|63.2|16.63
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]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.16||||83.16|59.88|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.16||||83.16|41.58|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.16||||83.16|41.58|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.16||||83.16|63.2|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.16||||83.16|57.38|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA [1260]|CIGNA PPO [126025]|83.16||||83.16|33.26|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.16||||83.16||63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|83.16||||83.16|57.38|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.16||||83.16|41.58|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.16||||83.16|57.38|63.2|16.63
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]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.16||||83.16|0|63.2|16.63
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]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|83.16||||83.16|57.38|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|Self-pay|Self-pay|83.16||||83.16|16.63|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|TML [1980]|TML [198000]|83.16||||83.16|57.38|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.16||||83.16|32.37|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.16||||83.16||63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNICARE [2040]|UNICARE [204000]|83.16||||83.16||63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.16||||83.16||63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WEB TPA [2115]|WEB TPA [211500]|83.16||||83.16|57.38|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.16||||83.16|0|63.2|16.63
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]|83.16||||83.16|0|63.2|16.63
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WORKER'S COMP [2125]|TML WC [212537]|83.16||||83.16||63.2|16.63
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AARP [1000]|AARP [100000]|8.07||||8.07||6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA [1015]|AETNA [101529]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.07||||8.07|4.04|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.07||||8.07|5.81|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.07||||8.07|4.04|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.07||||8.07|4.04|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.07||||8.07|6.13|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|8.07||||8.07|3.23|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.07||||8.07||6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.07||||8.07|4.04|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|Self-pay|Self-pay|8.07||||8.07|1.61|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|TML [1980]|TML [198000]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.07||||8.07|3.14|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.07||||8.07||6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|8.07||||8.07||6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.07||||8.07||6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|8.07||||8.07|5.57|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.07||||8.07|0|6.13|1.61
27471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|8.07||||8.07||6.13|1.61
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AARP [1000]|AARP [100000]|518.14||||518.14||393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA [1015]|AETNA [101529]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|518.14||||518.14|259.07|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|518.14||||518.14|373.06|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|518.14||||518.14|259.07|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|518.14||||518.14|259.07|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|518.14||||518.14|393.79|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|518.14||||518.14|207.26|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|518.14||||518.14||393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|518.14||||518.14|259.07|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|Self-pay|Self-pay|518.14||||518.14|103.63|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|TML [1980]|TML [198000]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|518.14||||518.14|201.66|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|518.14||||518.14||393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|518.14||||518.14||393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|518.14||||518.14||393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|518.14||||518.14|357.52|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|518.14||||518.14|0|393.79|103.63
27473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.3 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|518.14||||518.14||393.79|103.63
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|2237.18||||2237.18||1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2237.18||||2237.18|1118.59|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|1610.77|1700.26|447.44
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]|2237.18||||2237.18|1118.59|1700.26|447.44
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]|2237.18||||2237.18|1118.59|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2237.18||||2237.18|1700.26|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2237.18||||2237.18|1543.65|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|2237.18||||2237.18|894.87|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2237.18||||2237.18||1700.26|447.44
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]|2237.18||||2237.18|1543.65|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2237.18||||2237.18|1118.59|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2237.18||||2237.18|1543.65|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18|1543.65|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|2237.18||||2237.18|447.44|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|2237.18||||2237.18|1543.65|1700.26|447.44
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]|2237.18||||2237.18|870.71|1700.26|447.44
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]|2237.18||||2237.18||1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|2237.18||||2237.18||1700.26|447.44
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]|2237.18||||2237.18||1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|2237.18||||2237.18|1543.65|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
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]|2237.18||||2237.18|0|1700.26|447.44
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|2237.18||||2237.18||1700.26|447.44
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AARP [1000]|AARP [100000]|12.32||||12.32||9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AETNA [1015]|AETNA [101529]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.32||||12.32|4.79|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.32||||12.32|6.16|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.32||||12.32|4.79|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
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]|12.32||||12.32|8.87|9.36|2.46
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]|12.32||||12.32|6.16|9.36|2.46
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]|12.32||||12.32|6.16|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.32||||12.32|9.36|9.36|2.46
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]|12.32||||12.32|4.79|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.32||||12.32|8.5|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.32||||12.32|4.93|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.32||||12.32||9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.32||||12.32|8.5|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.32||||12.32|6.16|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.32||||12.32|8.5|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.32||||12.32|0|9.36|2.46
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]|12.32||||12.32|4.79|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.32||||12.32|0|9.36|2.46
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]|12.32||||12.32|4.79|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.32||||12.32|8.5|9.36|2.46
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]|12.32||||12.32|4.79|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|Self-pay|Self-pay|12.32||||12.32|2.46|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|TML [1980]|TML [198000]|12.32||||12.32|8.5|9.36|2.46
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]|12.32||||12.32|4.79|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.32||||12.32||9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.32||||12.32||9.36|2.46
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]|12.32||||12.32||9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.32||||12.32|8.5|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
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]|12.32||||12.32|0|9.36|2.46
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.32||||12.32||9.36|2.46
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|21.96||||21.96||16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.96||||21.96|10.98|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|15.81|16.69|4.39
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]|21.96||||21.96|10.98|16.69|4.39
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]|21.96||||21.96|10.98|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.96||||21.96|16.69|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.96||||21.96|15.15|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.96||||21.96|8.78|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.96||||21.96||16.69|4.39
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]|21.96||||21.96|15.15|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.96||||21.96|10.98|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.96||||21.96|15.15|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96|15.15|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|21.96||||21.96|4.39|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|21.96||||21.96|15.15|16.69|4.39
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]|21.96||||21.96|8.55|16.69|4.39
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]|21.96||||21.96||16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|21.96||||21.96||16.69|4.39
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]|21.96||||21.96||16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.96||||21.96|15.15|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
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]|21.96||||21.96|0|16.69|4.39
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|21.96||||21.96||16.69|4.39
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AARP [1000]|AARP [100000]|13.2||||13.2||10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AETNA [1015]|AETNA [101529]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|9.5|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|6.6|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.6|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|10.03|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2||10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|Self-pay|Self-pay|13.2||||13.2|2.64|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|TML [1980]|TML [198000]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|5.14|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2||10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UNICARE [2040]|UNICARE [204000]|13.2||||13.2||10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2||10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.2||||13.2|0|10.03|2.64
27644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 25 MG-DIPYRIDAMOLE 200 MG CAPSULE,EXT.RELEASE 12 HR MULTIPHASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2||10.03|2.64
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AARP [1000]|AARP [100000]|133.72||||133.72||101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA [1015]|AETNA [101529]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMBETTER [2930]|AMBETTER [293000]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|133.72||||133.72|66.86|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|133.72||||133.72|52.04|101.63|26.74
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]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133.72||||133.72|96.28|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133.72||||133.72|66.86|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133.72||||133.72|66.86|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|133.72||||133.72|101.63|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|133.72||||133.72|92.27|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA [1260]|CIGNA PPO [126025]|133.72||||133.72|53.49|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|133.72||||133.72||101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|133.72||||133.72|92.27|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|133.72||||133.72|66.86|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|133.72||||133.72|92.27|101.63|26.74
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]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133.72||||133.72|0|101.63|26.74
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]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|133.72||||133.72|92.27|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|Self-pay|Self-pay|133.72||||133.72|26.74|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|TML [1980]|TML [198000]|133.72||||133.72|92.27|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133.72||||133.72|52.04|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133.72||||133.72||101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNICARE [2040]|UNICARE [204000]|133.72||||133.72||101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133.72||||133.72||101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WEB TPA [2115]|WEB TPA [211500]|133.72||||133.72|92.27|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133.72||||133.72|0|101.63|26.74
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]|133.72||||133.72|0|101.63|26.74
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WORKER'S COMP [2125]|TML WC [212537]|133.72||||133.72||101.63|26.74
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|8.08||||8.08||6.14|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]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.08||||8.08|3.14|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.08||||8.08|0.03|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.08||||8.08|3.14|6.14|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]|8.08||||8.08|0|6.14|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]|8.08||||8.08|5.82|6.14|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]|8.08||||8.08|4.04|6.14|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]|8.08||||8.08|4.04|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.08||||8.08|6.14|6.14|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]|8.08||||8.08|3.14|6.14|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]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.08||||8.08|5.58|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.08||||8.08|3.23|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.08||||8.08||6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.08||||8.08|5.58|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.08||||8.08|0.03|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.08||||8.08|5.58|6.14|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]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.08||||8.08|0|6.14|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]|8.08||||8.08|3.14|6.14|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]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.08||||8.08|0|6.14|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]|8.08||||8.08|3.14|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.08||||8.08|5.58|6.14|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]|8.08||||8.08|3.14|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|8.08||||8.08|1.62|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|TML [1980]|TML [198000]|8.08||||8.08|5.58|6.14|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]|8.08||||8.08|3.14|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.08||||8.08||6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.08||||8.08||6.14|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]|8.08||||8.08||6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.08||||8.08|5.58|6.14|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]|8.08||||8.08|0|6.14|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]|8.08||||8.08|0|6.14|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.08||||8.08||6.14|0.03
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1162.92||||1162.92|0.14|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1162.92||||1162.92|837.3|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1162.92||||1162.92|883.82|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|1162.92||||1162.92|465.17|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1162.92||||1162.92|0.14|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1162.92||||1162.92|232.58|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|1162.92||||1162.92|802.41|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1162.92||||1162.92|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|1162.92||||1162.92|581.46|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.66||||594.66|0.14|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.66||||594.66|428.16|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.66||||594.66|451.94|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|594.66||||594.66|237.86|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.66||||594.66|0.14|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|594.66||||594.66|118.93|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.66||||594.66|297.33|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|594.66||||594.66|410.32|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.66||||594.66|0|883.82|0.14
27737|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 61 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|594.66||||594.66|297.33|883.82|0.14
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AARP [1000]|AARP [100000]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA [1015]|AETNA [101529]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|554.4||||554.4|277.2|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|554.4||||554.4|399.17|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|554.4||||554.4|277.2|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|554.4||||554.4|277.2|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|554.4||||554.4|421.34|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|554.4||||554.4|221.76|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|554.4||||554.4|277.2|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|Self-pay|Self-pay|554.4||||554.4|110.88|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|TML [1980]|TML [198000]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|554.4||||554.4|215.77|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNICARE [2040]|UNICARE [204000]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|554.4||||554.4|382.54|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|554.4||||554.4|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|554.4||||554.4||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AARP [1000]|AARP [100000]|594||||594||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA [1015]|AETNA [101529]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMBETTER [2930]|AMBETTER [293000]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594||||594|297|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|427.68|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|297|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|297|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594||||594|451.44|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA PPO [126025]|594||||594|237.6|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594||||594||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594||||594|297|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|Self-pay|Self-pay|594||||594|118.8|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|TML [1980]|TML [198000]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|231.18|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNICARE [2040]|UNICARE [204000]|594||||594||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594||451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WEB TPA [2115]|WEB TPA [211500]|594||||594|409.86|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594|0|451.44|110.88
27796|ERX|0250 - PHARMACY-GENERAL|PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TML WC [212537]|594||||594||451.44|110.88
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AARP [1000]|AARP [100000]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA [1015]|AETNA [101529]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMBETTER [2930]|AMBETTER [293000]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|495||||495|247.5|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|495||||495|356.4|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|495||||495|247.5|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|495||||495|247.5|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|495||||495|376.2|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA PPO [126025]|495||||495|198|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|495||||495|247.5|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|Self-pay|Self-pay|495||||495|99|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|TML [1980]|TML [198000]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|495||||495|192.65|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNICARE [2040]|UNICARE [204000]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WEB TPA [2115]|WEB TPA [211500]|495||||495|341.55|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|495||||495|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TML WC [212537]|495||||495||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AARP [1000]|AARP [100000]|554.4||||554.4||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AETNA [1015]|AETNA [101529]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMBETTER [2930]|AMBETTER [293000]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|554.4||||554.4|277.2|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|554.4||||554.4|399.17|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|554.4||||554.4|277.2|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|554.4||||554.4|277.2|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|554.4||||554.4|421.34|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|CIGNA [1260]|CIGNA PPO [126025]|554.4||||554.4|221.76|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|554.4||||554.4||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|554.4||||554.4|277.2|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|Self-pay|Self-pay|554.4||||554.4|110.88|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|TML [1980]|TML [198000]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|554.4||||554.4|215.77|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|554.4||||554.4||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNICARE [2040]|UNICARE [204000]|554.4||||554.4||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|554.4||||554.4||421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WEB TPA [2115]|WEB TPA [211500]|554.4||||554.4|382.54|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|554.4||||554.4|0|421.34|99
27800|ERX|0250 - PHARMACY-GENERAL|PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|3,000 mL|WORKER'S COMP [2125]|TML WC [212537]|554.4||||554.4||421.34|99
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AARP [1000]|AARP [100000]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AETNA [1015]|AETNA [101529]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|501.6||||501.6|250.8|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|501.6||||501.6|361.15|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|501.6||||501.6|250.8|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|501.6||||501.6|250.8|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|501.6||||501.6|381.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|501.6||||501.6|200.64|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|501.6||||501.6|250.8|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|Self-pay|Self-pay|501.6||||501.6|100.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|TML [1980]|TML [198000]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|501.6||||501.6|195.22|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNICARE [2040]|UNICARE [204000]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|501.6||||501.6|346.1|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|501.6||||501.6|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|501.6||||501.6||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AARP [1000]|AARP [100000]|528||||528||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AETNA [1015]|AETNA [101529]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMBETTER [2930]|AMBETTER [293000]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528||||528|264|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528||||528|380.16|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528||||528|264|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528||||528|264|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528||||528|401.28|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|CIGNA [1260]|CIGNA PPO [126025]|528||||528|211.2|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528||||528||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528||||528|264|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|Self-pay|Self-pay|528||||528|105.6|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|TML [1980]|TML [198000]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528||||528|205.5|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528||||528||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNICARE [2040]|UNICARE [204000]|528||||528||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528||||528||401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WEB TPA [2115]|WEB TPA [211500]|528||||528|364.32|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528||||528|0|401.28|100.32
27804|ERX|0250 - PHARMACY-GENERAL|PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L|2,500 mL|WORKER'S COMP [2125]|TML WC [212537]|528||||528||401.28|100.32
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|26.4||||26.4|13.2|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.4||||26.4|3.55|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.4||||26.4|10.27|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|19.01|30.1|0.88
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]|26.4||||26.4|13.2|30.1|0.88
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]|26.4||||26.4|13.2|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.4||||26.4|20.06|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.4||||26.4|18.22|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|26.4||||26.4|10.56|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.4||||26.4|13.2|30.1|0.88
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]|26.4||||26.4|18.22|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.4||||26.4|3.55|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.4||||26.4|18.22|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.4||||26.4|18.22|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|26.4||||26.4|5.28|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|TML [1980]|TML [198000]|26.4||||26.4|18.22|30.1|0.88
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]|26.4||||26.4|10.27|30.1|0.88
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]|26.4||||26.4|13.2|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNICARE [2040]|UNICARE [204000]|26.4||||26.4|13.2|30.1|0.88
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]|26.4||||26.4|13.2|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|26.4||||26.4|18.22|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
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]|26.4||||26.4|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|26.4||||26.4|13.2|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AARP [1000]|AARP [100000]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AETNA [1015]|AETNA [101529]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMBETTER [2930]|AMBETTER [293000]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.04||||29.04|0.88|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.04||||29.04|20.91|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.04||||29.04|22.07|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|CIGNA [1260]|CIGNA PPO [126025]|29.04||||29.04|11.62|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.04||||29.04|0.88|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|Self-pay|Self-pay|29.04||||29.04|5.81|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|TML [1980]|TML [198000]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.04||||29.04|11.3|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UNICARE [2040]|UNICARE [204000]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WEB TPA [2115]|WEB TPA [211500]|29.04||||29.04|20.04|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.04||||29.04|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|100 mL|WORKER'S COMP [2125]|TML WC [212537]|29.04||||29.04|14.52|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AARP [1000]|AARP [100000]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AETNA [1015]|AETNA [101529]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|0.88|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|23.76|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|0.88|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|Self-pay|Self-pay|33||||33|6.6|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|TML [1980]|TML [198000]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|12.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UNICARE [2040]|UNICARE [204000]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|250 mL|WORKER'S COMP [2125]|TML WC [212537]|33||||33|16.5|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|1.78|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|28.51|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|1.78|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|15.41|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|19.8|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6|0|30.1|0.88
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|500 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|30.1|0.88
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]|3.37||||3.37||2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.37||||3.37|1.69|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|2.43|2.56|0.67
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]|3.37||||3.37|1.69|2.56|0.67
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]|3.37||||3.37|1.69|2.56|0.67
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 TRADITIONAL OF TEXAS [115503]|3.37||||3.37|2.56|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.37||||3.37|2.33|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|3.37||||3.37|1.35|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.37||||3.37||2.56|0.67
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]|3.37||||3.37|2.33|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.37||||3.37|1.69|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.37||||3.37|2.33|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37|2.33|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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|3.37||||3.37|0.67|2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|3.37||||3.37|2.33|2.56|0.67
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]|3.37||||3.37|1.31|2.56|0.67
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]|3.37||||3.37||2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|3.37||||3.37||2.56|0.67
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]|3.37||||3.37||2.56|0.67
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|3.37||||3.37|2.33|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|3.37||||3.37|0|2.56|0.67
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]|TML WC [212537]|3.37||||3.37||2.56|0.67
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.63||||22.63|11.32|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|16.29|17.2|4.53
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]|22.63||||22.63|11.32|17.2|4.53
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]|22.63||||22.63|11.32|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.63||||22.63|17.2|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.63||||22.63|15.61|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|22.63||||22.63|9.05|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63|15.61|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.63||||22.63|11.32|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|22.63||||22.63|4.53|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63||17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63||17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|22.63||||22.63||17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.63||||22.63|11.32|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|16.29|17.2|4.53
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]|22.63||||22.63|11.32|17.2|4.53
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]|22.63||||22.63|11.32|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.63||||22.63|17.2|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.63||||22.63|15.61|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|22.63||||22.63|9.05|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63|15.61|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.63||||22.63|11.32|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|22.63||||22.63|4.53|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|8.81|17.2|4.53
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]|22.63||||22.63||17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|22.63||||22.63||17.2|4.53
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]|22.63||||22.63||17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|22.63||||22.63|15.61|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
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]|22.63||||22.63|0|17.2|4.53
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|22.63||||22.63||17.2|4.53
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|94.12||||94.12||71.53|18.82
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]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94.12||||94.12|36.63|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|94.12||||94.12|47.06|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|94.12||||94.12|36.63|71.53|18.82
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]|94.12||||94.12|0|71.53|18.82
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]|94.12||||94.12|67.77|71.53|18.82
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]|94.12||||94.12|47.06|71.53|18.82
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]|94.12||||94.12|47.06|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|94.12||||94.12|71.53|71.53|18.82
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]|94.12||||94.12|36.63|71.53|18.82
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]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|94.12||||94.12|64.94|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|94.12||||94.12|37.65|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|94.12||||94.12||71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|94.12||||94.12|64.94|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|94.12||||94.12|47.06|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|94.12||||94.12|64.94|71.53|18.82
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]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94.12||||94.12|36.63|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94.12||||94.12|0|71.53|18.82
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]|94.12||||94.12|36.63|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|94.12||||94.12|64.94|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94.12||||94.12|36.63|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|94.12||||94.12|18.82|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|94.12||||94.12|64.94|71.53|18.82
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]|94.12||||94.12|36.63|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94.12||||94.12||71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|94.12||||94.12||71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94.12||||94.12||71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|94.12||||94.12|64.94|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94.12||||94.12|0|71.53|18.82
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]|94.12||||94.12|0|71.53|18.82
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|94.12||||94.12||71.53|18.82
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|167.2||||167.2||127.07|33.44
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]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167.2||||167.2|65.07|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|167.2||||167.2|83.6|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|167.2||||167.2|65.07|127.07|33.44
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]|167.2||||167.2|0|127.07|33.44
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]|167.2||||167.2|120.38|127.07|33.44
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]|167.2||||167.2|83.6|127.07|33.44
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]|167.2||||167.2|83.6|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|167.2||||167.2|127.07|127.07|33.44
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]|167.2||||167.2|65.07|127.07|33.44
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]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|167.2||||167.2|115.37|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|167.2||||167.2|66.88|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|167.2||||167.2||127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|167.2||||167.2|115.37|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|167.2||||167.2|83.6|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|167.2||||167.2|115.37|127.07|33.44
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]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167.2||||167.2|65.07|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167.2||||167.2|0|127.07|33.44
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]|167.2||||167.2|65.07|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|167.2||||167.2|115.37|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167.2||||167.2|65.07|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|167.2||||167.2|33.44|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|167.2||||167.2|115.37|127.07|33.44
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]|167.2||||167.2|65.07|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167.2||||167.2||127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|167.2||||167.2||127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167.2||||167.2||127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|167.2||||167.2|115.37|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167.2||||167.2|0|127.07|33.44
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]|167.2||||167.2|0|127.07|33.44
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|167.2||||167.2||127.07|33.44
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|363.77||||363.77||276.47|72.75
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]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363.77||||363.77|141.58|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|363.77||||363.77|181.89|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|363.77||||363.77|141.58|276.47|72.75
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]|363.77||||363.77|0|276.47|72.75
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]|363.77||||363.77|261.91|276.47|72.75
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]|363.77||||363.77|181.89|276.47|72.75
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]|363.77||||363.77|181.89|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|363.77||||363.77|276.47|276.47|72.75
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]|363.77||||363.77|141.58|276.47|72.75
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]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|363.77||||363.77|251|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|363.77||||363.77|145.51|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|363.77||||363.77||276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|363.77||||363.77|251|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|363.77||||363.77|181.89|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|363.77||||363.77|251|276.47|72.75
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]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363.77||||363.77|141.58|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363.77||||363.77|0|276.47|72.75
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]|363.77||||363.77|141.58|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|363.77||||363.77|251|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363.77||||363.77|141.58|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|363.77||||363.77|72.75|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|363.77||||363.77|251|276.47|72.75
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]|363.77||||363.77|141.58|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363.77||||363.77||276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|363.77||||363.77||276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363.77||||363.77||276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|363.77||||363.77|251|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363.77||||363.77|0|276.47|72.75
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]|363.77||||363.77|0|276.47|72.75
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|363.77||||363.77||276.47|72.75
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|541.2||||541.2||411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|541.2||||541.2|270.6|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|541.2||||541.2|389.66|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|541.2||||541.2|270.6|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|541.2||||541.2|270.6|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|541.2||||541.2|411.31|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|541.2||||541.2|216.48|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|541.2||||541.2||411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|541.2||||541.2|270.6|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|541.2||||541.2|108.24|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|541.2||||541.2|210.64|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|541.2||||541.2||411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|541.2||||541.2||411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|541.2||||541.2||411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|541.2||||541.2|373.43|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|541.2||||541.2|0|411.31|108.24
27931|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 15 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|541.2||||541.2|270.6|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|541.2||||541.2|389.66|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|541.2||||541.2|270.6|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|541.2||||541.2|270.6|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|541.2||||541.2|411.31|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|541.2||||541.2|216.48|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|541.2||||541.2|270.6|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|541.2||||541.2|108.24|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|541.2||||541.2|210.64|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|541.2||||541.2||411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|541.2||||541.2|373.43|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|541.2||||541.2|0|411.31|108.24
27946|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 2.75 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|541.2||||541.2||411.31|108.24
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AARP [1000]|AARP [100000]|1056||||1056||802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AETNA [1015]|AETNA [101529]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1056||||1056|528|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1056||||1056|760.32|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1056||||1056|528|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1056||||1056|528|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1056||||1056|802.56|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|1056||||1056|422.4|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1056||||1056||802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1056||||1056|528|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|Self-pay|Self-pay|1056||||1056|211.2|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|TML [1980]|TML [198000]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1056||||1056|411|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1056||||1056||802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|UNICARE [2040]|UNICARE [204000]|1056||||1056||802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1056||||1056||802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|1056||||1056|728.64|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1056||||1056|0|802.56|211.2
27963|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 %-DEXTROSE 15 %-ELECTROLYTES INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|1056||||1056||802.56|211.2
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AARP [1000]|AARP [100000]|1082.4||||1082.4||822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AETNA [1015]|AETNA [101529]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AMBETTER [2930]|AMBETTER [293000]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1082.4||||1082.4|541.2|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1082.4||||1082.4|421.27|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|779.33|822.62|216.48
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]|1082.4||||1082.4|541.2|822.62|216.48
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]|1082.4||||1082.4|541.2|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1082.4||||1082.4|822.62|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1082.4||||1082.4|746.86|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA PPO [126025]|1082.4||||1082.4|432.96|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1082.4||||1082.4||822.62|216.48
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]|1082.4||||1082.4|746.86|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1082.4||||1082.4|541.2|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1082.4||||1082.4|746.86|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1082.4||||1082.4|746.86|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|Self-pay|Self-pay|1082.4||||1082.4|216.48|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|TML [1980]|TML [198000]|1082.4||||1082.4|746.86|822.62|216.48
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]|1082.4||||1082.4|421.27|822.62|216.48
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]|1082.4||||1082.4||822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UNICARE [2040]|UNICARE [204000]|1082.4||||1082.4||822.62|216.48
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]|1082.4||||1082.4||822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|WEB TPA [2115]|WEB TPA [211500]|1082.4||||1082.4|746.86|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
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]|1082.4||||1082.4|0|822.62|216.48
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TML WC [212537]|1082.4||||1082.4||822.62|216.48
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|78.21||||78.21||59.44|15.64
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]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.21||||78.21|30.44|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|78.21||||78.21|39.11|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|78.21||||78.21|30.44|59.44|15.64
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]|78.21||||78.21|0|59.44|15.64
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]|78.21||||78.21|56.31|59.44|15.64
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]|78.21||||78.21|39.11|59.44|15.64
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]|78.21||||78.21|39.11|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|78.21||||78.21|59.44|59.44|15.64
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]|78.21||||78.21|30.44|59.44|15.64
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]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|78.21||||78.21|53.96|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|78.21||||78.21|31.28|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|78.21||||78.21||59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|78.21||||78.21|53.96|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|78.21||||78.21|39.11|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|78.21||||78.21|53.96|59.44|15.64
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]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.21||||78.21|30.44|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.21||||78.21|0|59.44|15.64
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]|78.21||||78.21|30.44|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|78.21||||78.21|53.96|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.21||||78.21|30.44|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|Self-pay|Self-pay|78.21||||78.21|15.64|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|TML [1980]|TML [198000]|78.21||||78.21|53.96|59.44|15.64
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]|78.21||||78.21|30.44|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.21||||78.21||59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|78.21||||78.21||59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.21||||78.21||59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|78.21||||78.21|53.96|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.21||||78.21|0|59.44|15.64
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]|78.21||||78.21|0|59.44|15.64
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|78.21||||78.21||59.44|15.64
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AARP [1000]|AARP [100000]|66.93||||66.93||50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AETNA [1015]|AETNA [101529]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AMBETTER [2930]|AMBETTER [293000]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66.93||||66.93|33.47|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.93||||66.93|48.19|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.93||||66.93|33.47|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.93||||66.93|33.47|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66.93||||66.93|50.87|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|CIGNA [1260]|CIGNA PPO [126025]|66.93||||66.93|26.77|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66.93||||66.93||50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|GROUP PENSION ADMIN [1450]|GPA [145000]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66.93||||66.93|33.47|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|PHCS [1780]|PHCS MULTIPLAN [178000]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|Self-pay|Self-pay|66.93||||66.93|13.39|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|TML [1980]|TML [198000]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.93||||66.93|26.05|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.93||||66.93||50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|UNICARE [2040]|UNICARE [204000]|66.93||||66.93||50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.93||||66.93||50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|WEB TPA [2115]|WEB TPA [211500]|66.93||||66.93|46.18|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.93||||66.93|0|50.87|13.39
28048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL|78 g|WORKER'S COMP [2125]|TML WC [212537]|66.93||||66.93||50.87|13.39
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AARP [1000]|AARP [100000]|18.7||||18.7||14.21|3.74
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]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AETNA [1015]|AETNA [101529]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMBETTER [2930]|AMBETTER [293000]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.7||||18.7|7.28|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.7||||18.7|9.35|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.7||||18.7|7.28|14.21|3.74
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]|18.7||||18.7|0|14.21|3.74
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]|18.7||||18.7|13.46|14.21|3.74
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]|18.7||||18.7|9.35|14.21|3.74
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]|18.7||||18.7|9.35|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.7||||18.7|14.21|14.21|3.74
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]|18.7||||18.7|7.28|14.21|3.74
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]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.7||||18.7|12.9|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA [1260]|CIGNA PPO [126025]|18.7||||18.7|7.48|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.7||||18.7||14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.7||||18.7|12.9|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.7||||18.7|9.35|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.7||||18.7|12.9|14.21|3.74
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]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.7||||18.7|7.28|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.7||||18.7|0|14.21|3.74
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]|18.7||||18.7|7.28|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.7||||18.7|12.9|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.7||||18.7|7.28|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|Self-pay|Self-pay|18.7||||18.7|3.74|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|TML [1980]|TML [198000]|18.7||||18.7|12.9|14.21|3.74
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]|18.7||||18.7|7.28|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.7||||18.7||14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNICARE [2040]|UNICARE [204000]|18.7||||18.7||14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.7||||18.7||14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WEB TPA [2115]|WEB TPA [211500]|18.7||||18.7|12.9|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.7||||18.7|0|14.21|3.74
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]|18.7||||18.7|0|14.21|3.74
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WORKER'S COMP [2125]|TML WC [212537]|18.7||||18.7||14.21|3.74
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|208.83||||208.83||158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|208.83||||208.83|104.42|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|208.83||||208.83|81.28|158.71|41.77
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]|208.83||||208.83|0|158.71|41.77
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]|208.83||||208.83|150.36|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|208.83||||208.83|104.42|158.71|41.77
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]|208.83||||208.83|104.42|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|208.83||||208.83|158.71|158.71|41.77
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]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|208.83||||208.83|144.09|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|208.83||||208.83|83.53|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|208.83||||208.83||158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|208.83||||208.83|144.09|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|208.83||||208.83|104.42|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|208.83||||208.83|144.09|158.71|41.77
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]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|208.83||||208.83|0|158.71|41.77
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]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|208.83||||208.83|144.09|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|208.83||||208.83|41.77|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|TML [1980]|TML [198000]|208.83||||208.83|144.09|158.71|41.77
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]|208.83||||208.83|81.28|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|208.83||||208.83||158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|208.83||||208.83||158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|208.83||||208.83||158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|208.83||||208.83|144.09|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|208.83||||208.83|0|158.71|41.77
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]|208.83||||208.83|0|158.71|41.77
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|208.83||||208.83||158.71|41.77
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AARP [1000]|AARP [100000]|39.54||||39.54||30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.54||||39.54|19.77|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.54||||39.54|15.39|30.05|7.91
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]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.54||||39.54|28.47|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.54||||39.54|19.77|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.54||||39.54|19.77|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.54||||39.54|30.05|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.54||||39.54|27.28|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|39.54||||39.54|15.82|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.54||||39.54||30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|39.54||||39.54|27.28|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.54||||39.54|19.77|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.54||||39.54|27.28|30.05|7.91
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]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.54||||39.54|0|30.05|7.91
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]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|39.54||||39.54|27.28|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|Self-pay|Self-pay|39.54||||39.54|7.91|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|TML [1980]|TML [198000]|39.54||||39.54|27.28|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.54||||39.54|15.39|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.54||||39.54||30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|39.54||||39.54||30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.54||||39.54||30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|39.54||||39.54|27.28|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.54||||39.54|0|30.05|7.91
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]|39.54||||39.54|0|30.05|7.91
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|39.54||||39.54||30.05|7.91
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AARP [1000]|AARP [100000]|8658.54||||8658.54||6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AETNA [1015]|AETNA [101529]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AMBETTER [2930]|AMBETTER [293000]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8658.54||||8658.54|4329.27|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8658.54||||8658.54|6234.15|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8658.54||||8658.54|4329.27|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8658.54||||8658.54|4329.27|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8658.54||||8658.54|6580.49|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|CIGNA [1260]|CIGNA PPO [126025]|8658.54||||8658.54|3463.42|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8658.54||||8658.54||6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8658.54||||8658.54|4329.27|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|Self-pay|Self-pay|8658.54||||8658.54|1731.71|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|TML [1980]|TML [198000]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8658.54||||8658.54|3369.9|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8658.54||||8658.54||6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|UNICARE [2040]|UNICARE [204000]|8658.54||||8658.54||6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8658.54||||8658.54||6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|WEB TPA [2115]|WEB TPA [211500]|8658.54||||8658.54|5974.39|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8658.54||||8658.54|0|6580.49|1731.71
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|150 mL|WORKER'S COMP [2125]|TML WC [212537]|8658.54||||8658.54||6580.49|1731.71
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]|1627.56||||1627.56||1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMBETTER [2930]|AMBETTER [293000]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1627.56||||1627.56|9.19|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|1171.84|1236.95|9.19
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]|1627.56||||1627.56|813.78|1236.95|9.19
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]|1627.56||||1627.56|813.78|1236.95|9.19
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 TRADITIONAL OF TEXAS [115503]|1627.56||||1627.56|1236.95|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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 - GREAT WEST [126009]|1627.56||||1627.56|1123.02|1236.95|9.19
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 PPO [126025]|1627.56||||1627.56|651.02|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1627.56||||1627.56||1236.95|9.19
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]|1627.56||||1627.56|1123.02|1236.95|9.19
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1627.56||||1627.56|9.19|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1627.56||||1627.56|1123.02|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56|1123.02|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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|1627.56||||1627.56|325.51|1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|TML [1980]|TML [198000]|1627.56||||1627.56|1123.02|1236.95|9.19
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]|1627.56||||1627.56|633.45|1236.95|9.19
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]|1627.56||||1627.56||1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNICARE [2040]|UNICARE [204000]|1627.56||||1627.56||1236.95|9.19
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]|1627.56||||1627.56||1236.95|9.19
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WEB TPA [2115]|WEB TPA [211500]|1627.56||||1627.56|1123.02|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|1627.56||||1627.56|0|1236.95|9.19
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]|TML WC [212537]|1627.56||||1627.56||1236.95|9.19
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AARP [1000]|AARP [100000]|2202.95||||2202.95||1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AETNA [1015]|AETNA [101529]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AMBETTER [2930]|AMBETTER [293000]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2202.95||||2202.95|1101.48|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2202.95||||2202.95|1586.12|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2202.95||||2202.95|1101.48|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2202.95||||2202.95|1101.48|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2202.95||||2202.95|1674.24|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA [1260]|CIGNA PPO [126025]|2202.95||||2202.95|881.18|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2202.95||||2202.95||1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2202.95||||2202.95|1101.48|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|Self-pay|Self-pay|2202.95||||2202.95|440.59|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|TML [1980]|TML [198000]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2202.95||||2202.95|857.39|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2202.95||||2202.95||1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UNICARE [2040]|UNICARE [204000]|2202.95||||2202.95||1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2202.95||||2202.95||1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WEB TPA [2115]|WEB TPA [211500]|2202.95||||2202.95|1520.04|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2202.95||||2202.95|0|1674.24|440.59
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WORKER'S COMP [2125]|TML WC [212537]|2202.95||||2202.95||1674.24|440.59
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|38.34||||38.34||29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.34||||38.34|19.17|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.34||||38.34|14.92|29.14|7.67
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]|38.34||||38.34|0|29.14|7.67
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]|38.34||||38.34|27.6|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.34||||38.34|19.17|29.14|7.67
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]|38.34||||38.34|19.17|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.34||||38.34|29.14|29.14|7.67
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]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.34||||38.34|26.45|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|38.34||||38.34|15.34|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.34||||38.34||29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|38.34||||38.34|26.45|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.34||||38.34|19.17|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.34||||38.34|26.45|29.14|7.67
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]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.34||||38.34|0|29.14|7.67
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]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|38.34||||38.34|26.45|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|38.34||||38.34|7.67|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|38.34||||38.34|26.45|29.14|7.67
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]|38.34||||38.34|14.92|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.34||||38.34||29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|38.34||||38.34||29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.34||||38.34||29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|38.34||||38.34|26.45|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.34||||38.34|0|29.14|7.67
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]|38.34||||38.34|0|29.14|7.67
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|38.34||||38.34||29.14|7.67
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|3743||||3743|1871.5|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3743||||3743|1871.5|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|2694.96|2844.68|748.6
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]|3743||||3743|1871.5|2844.68|748.6
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]|3743||||3743|1871.5|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3743||||3743|2844.68|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3743||||3743|2582.67|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|3743||||3743|1497.2|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3743||||3743|1871.5|2844.68|748.6
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]|3743||||3743|2582.67|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3743||||3743|1871.5|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3743||||3743|2582.67|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|2582.67|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|Self-pay|Self-pay|3743||||3743|748.6|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|TML [1980]|TML [198000]|3743||||3743|2582.67|2844.68|748.6
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]|3743||||3743|1456.78|2844.68|748.6
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]|3743||||3743|1871.5|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|3743||||3743|1871.5|2844.68|748.6
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]|3743||||3743|1871.5|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|3743||||3743|2582.67|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
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]|3743||||3743|0|2844.68|748.6
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|3743||||3743|1871.5|2844.68|748.6
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.71||||2.71||2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.71||||2.71|1.05|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.71||||2.71|1.36|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.71||||2.71|1.05|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
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]|2.71||||2.71|1.95|2.06|0.54
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]|2.71||||2.71|1.36|2.06|0.54
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]|2.71||||2.71|1.36|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.71||||2.71|2.06|2.06|0.54
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]|2.71||||2.71|1.05|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.71||||2.71|1.87|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.71||||2.71|1.08|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.71||||2.71||2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.71||||2.71|1.87|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.71||||2.71|1.36|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.71||||2.71|1.87|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.71||||2.71|0|2.06|0.54
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]|2.71||||2.71|1.05|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.71||||2.71|0|2.06|0.54
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]|2.71||||2.71|1.05|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.71||||2.71|1.87|2.06|0.54
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]|2.71||||2.71|1.05|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|2.71||||2.71|0.54|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.71||||2.71|1.87|2.06|0.54
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]|2.71||||2.71|1.05|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.71||||2.71||2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.71||||2.71||2.06|0.54
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]|2.71||||2.71||2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.71||||2.71|1.87|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
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]|2.71||||2.71|0|2.06|0.54
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.71||||2.71||2.06|0.54
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6||30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|28.51|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|19.8|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|15.41|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6||30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||30.1|7.92
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|197.48||||197.48|1.11|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|197.48||||197.48|142.19|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|197.48||||197.48|150.08|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|197.48||||197.48|78.99|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|197.48||||197.48|1.11|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|Self-pay|Self-pay|197.48||||197.48|39.5|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|197.48||||197.48|76.86|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|197.48||||197.48|98.74|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|197.48||||197.48|136.26|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|197.48||||197.48|0|150.08|1.11
2850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|197.48||||197.48|98.74|150.08|1.11
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|99.43||||99.43||75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMBETTER [2930]|AMBETTER [293000]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99.43||||99.43|49.72|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99.43||||99.43|38.7|75.57|19.89
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]|99.43||||99.43|0|75.57|19.89
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]|99.43||||99.43|71.59|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99.43||||99.43|49.72|75.57|19.89
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]|99.43||||99.43|49.72|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99.43||||99.43|75.57|75.57|19.89
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]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99.43||||99.43|68.61|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|99.43||||99.43|39.77|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99.43||||99.43||75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|99.43||||99.43|68.61|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99.43||||99.43|49.72|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99.43||||99.43|68.61|75.57|19.89
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]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99.43||||99.43|0|75.57|19.89
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]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|99.43||||99.43|68.61|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|99.43||||99.43|19.89|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TML [1980]|TML [198000]|99.43||||99.43|68.61|75.57|19.89
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]|99.43||||99.43|38.7|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99.43||||99.43||75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNICARE [2040]|UNICARE [204000]|99.43||||99.43||75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99.43||||99.43||75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WEB TPA [2115]|WEB TPA [211500]|99.43||||99.43|68.61|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99.43||||99.43|0|75.57|19.89
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]|99.43||||99.43|0|75.57|19.89
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|99.43||||99.43||75.57|19.89
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|117.01||||117.01||88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMBETTER [2930]|AMBETTER [293000]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|117.01||||117.01|58.51|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|117.01||||117.01|45.54|88.93|23.4
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]|117.01||||117.01|0|88.93|23.4
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]|117.01||||117.01|84.25|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117.01||||117.01|58.51|88.93|23.4
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]|117.01||||117.01|58.51|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|117.01||||117.01|88.93|88.93|23.4
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]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|117.01||||117.01|80.74|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|117.01||||117.01|46.8|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|117.01||||117.01||88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|117.01||||117.01|80.74|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|117.01||||117.01|58.51|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|117.01||||117.01|80.74|88.93|23.4
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]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117.01||||117.01|0|88.93|23.4
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]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|117.01||||117.01|80.74|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|117.01||||117.01|23.4|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TML [1980]|TML [198000]|117.01||||117.01|80.74|88.93|23.4
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]|117.01||||117.01|45.54|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117.01||||117.01||88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNICARE [2040]|UNICARE [204000]|117.01||||117.01||88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117.01||||117.01||88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WEB TPA [2115]|WEB TPA [211500]|117.01||||117.01|80.74|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117.01||||117.01|0|88.93|23.4
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]|117.01||||117.01|0|88.93|23.4
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|117.01||||117.01||88.93|23.4
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AARP [1000]|AARP [100000]|262.55||||262.55||199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AETNA [1015]|AETNA [101529]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMBETTER [2930]|AMBETTER [293000]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|262.55||||262.55|131.28|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|262.55||||262.55|102.18|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|189.04|199.54|52.51
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]|262.55||||262.55|131.28|199.54|52.51
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]|262.55||||262.55|131.28|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|262.55||||262.55|199.54|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|262.55||||262.55|181.16|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA [1260]|CIGNA PPO [126025]|262.55||||262.55|105.02|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|262.55||||262.55||199.54|52.51
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]|262.55||||262.55|181.16|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|262.55||||262.55|131.28|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|262.55||||262.55|181.16|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|262.55||||262.55|181.16|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|Self-pay|Self-pay|262.55||||262.55|52.51|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|TML [1980]|TML [198000]|262.55||||262.55|181.16|199.54|52.51
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]|262.55||||262.55|102.18|199.54|52.51
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]|262.55||||262.55||199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNICARE [2040]|UNICARE [204000]|262.55||||262.55||199.54|52.51
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]|262.55||||262.55||199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WEB TPA [2115]|WEB TPA [211500]|262.55||||262.55|181.16|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
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]|262.55||||262.55|0|199.54|52.51
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WORKER'S COMP [2125]|TML WC [212537]|262.55||||262.55||199.54|52.51
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AARP [1000]|AARP [100000]|393.91||||393.91||299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AETNA [1015]|AETNA [101529]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMBETTER [2930]|AMBETTER [293000]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|393.91||||393.91|196.96|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|393.91||||393.91|153.31|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|283.62|299.37|78.78
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]|393.91||||393.91|196.96|299.37|78.78
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]|393.91||||393.91|196.96|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|393.91||||393.91|299.37|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|393.91||||393.91|271.8|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA [1260]|CIGNA PPO [126025]|393.91||||393.91|157.56|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|393.91||||393.91||299.37|78.78
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]|393.91||||393.91|271.8|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|393.91||||393.91|196.96|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|393.91||||393.91|271.8|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|393.91||||393.91|271.8|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|Self-pay|Self-pay|393.91||||393.91|78.78|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|TML [1980]|TML [198000]|393.91||||393.91|271.8|299.37|78.78
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]|393.91||||393.91|153.31|299.37|78.78
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]|393.91||||393.91||299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNICARE [2040]|UNICARE [204000]|393.91||||393.91||299.37|78.78
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]|393.91||||393.91||299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WEB TPA [2115]|WEB TPA [211500]|393.91||||393.91|271.8|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
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]|393.91||||393.91|0|299.37|78.78
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WORKER'S COMP [2125]|TML WC [212537]|393.91||||393.91||299.37|78.78
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|153.18||||153.18||116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|153.18||||153.18|76.59|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|153.18||||153.18|110.29|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|153.18||||153.18|76.59|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|153.18||||153.18|76.59|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|153.18||||153.18|116.42|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|153.18||||153.18|61.27|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|153.18||||153.18||116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|153.18||||153.18|76.59|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|153.18||||153.18|30.64|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|153.18||||153.18|59.62|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|153.18||||153.18||116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|153.18||||153.18||116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|153.18||||153.18||116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|153.18||||153.18|105.69|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|153.18||||153.18|0|116.42|30.64
2889|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|153.18||||153.18||116.42|30.64
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|4263.6||||4263.6||3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4263.6||||4263.6|1659.39|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4263.6||||4263.6|1.89|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4263.6||||4263.6|1659.39|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
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]|4263.6||||4263.6|3069.79|3240.34|1.89
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]|4263.6||||4263.6|2131.8|3240.34|1.89
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]|4263.6||||4263.6|2131.8|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4263.6||||4263.6|3240.34|3240.34|1.89
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]|4263.6||||4263.6|1659.39|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4263.6||||4263.6|2941.88|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA [1260]|CIGNA PPO [126025]|4263.6||||4263.6|1705.44|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4263.6||||4263.6||3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4263.6||||4263.6|2941.88|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4263.6||||4263.6|1.89|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4263.6||||4263.6|2941.88|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4263.6||||4263.6|0|3240.34|1.89
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]|4263.6||||4263.6|1659.39|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4263.6||||4263.6|0|3240.34|1.89
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]|4263.6||||4263.6|1659.39|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4263.6||||4263.6|2941.88|3240.34|1.89
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]|4263.6||||4263.6|1659.39|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|Self-pay|Self-pay|4263.6||||4263.6|852.72|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|TML [1980]|TML [198000]|4263.6||||4263.6|2941.88|3240.34|1.89
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]|4263.6||||4263.6|1659.39|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4263.6||||4263.6||3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNICARE [2040]|UNICARE [204000]|4263.6||||4263.6||3240.34|1.89
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]|4263.6||||4263.6||3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|4263.6||||4263.6|2941.88|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
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]|4263.6||||4263.6|0|3240.34|1.89
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WORKER'S COMP [2125]|TML WC [212537]|4263.6||||4263.6||3240.34|1.89
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AARP [1000]|AARP [100000]|8733.12||||8733.12||6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8733.12||||8733.12|4366.56|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8733.12||||8733.12|6287.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8733.12||||8733.12|4366.56|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8733.12||||8733.12|4366.56|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8733.12||||8733.12|6637.17|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|8733.12||||8733.12|3493.25|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8733.12||||8733.12||6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8733.12||||8733.12|4366.56|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|Self-pay|Self-pay|8733.12||||8733.12|1746.62|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|TML [1980]|TML [198000]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8733.12||||8733.12|3398.93|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8733.12||||8733.12||6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UNICARE [2040]|UNICARE [204000]|8733.12||||8733.12||6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8733.12||||8733.12||6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|8733.12||||8733.12|6025.85|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8733.12||||8733.12|0|6637.17|1746.62
2900|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|8733.12||||8733.12||6637.17|1746.62
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|1079.82||||1079.82||820.66|99.91
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]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1079.82||||1079.82|420.27|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1079.82||||1079.82|99.91|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1079.82||||1079.82|420.27|820.66|99.91
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]|1079.82||||1079.82|0|820.66|99.91
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]|1079.82||||1079.82|777.47|820.66|99.91
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]|1079.82||||1079.82|539.91|820.66|99.91
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]|1079.82||||1079.82|539.91|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1079.82||||1079.82|820.66|820.66|99.91
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]|1079.82||||1079.82|420.27|820.66|99.91
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]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1079.82||||1079.82|745.08|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|1079.82||||1079.82|431.93|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1079.82||||1079.82||820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1079.82||||1079.82|745.08|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1079.82||||1079.82|99.91|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1079.82||||1079.82|745.08|820.66|99.91
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]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1079.82||||1079.82|420.27|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1079.82||||1079.82|0|820.66|99.91
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]|1079.82||||1079.82|420.27|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1079.82||||1079.82|745.08|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1079.82||||1079.82|420.27|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|1079.82||||1079.82|215.96|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|1079.82||||1079.82|745.08|820.66|99.91
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]|1079.82||||1079.82|420.27|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1079.82||||1079.82||820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|1079.82||||1079.82||820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1079.82||||1079.82||820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|1079.82||||1079.82|745.08|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1079.82||||1079.82|0|820.66|99.91
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]|1079.82||||1079.82|0|820.66|99.91
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|1079.82||||1079.82||820.66|99.91
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|726||||726|363|551.76|0.29
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]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|726||||726|0|551.76|0.29
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]|726||||726|282.56|551.76|0.29
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]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|726||||726|0.29|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|726||||726|282.56|551.76|0.29
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]|726||||726|0|551.76|0.29
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]|726||||726|522.72|551.76|0.29
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]|726||||726|363|551.76|0.29
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]|726||||726|363|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|726||||726|551.76|551.76|0.29
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]|726||||726|282.56|551.76|0.29
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]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|726||||726|500.94|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|726||||726|290.4|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|726||||726|363|551.76|0.29
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]|726||||726|500.94|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|726||||726|0.29|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|726||||726|500.94|551.76|0.29
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]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|726||||726|0|551.76|0.29
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]|726||||726|282.56|551.76|0.29
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]|726||||726|0|551.76|0.29
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]|726||||726|0|551.76|0.29
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]|726||||726|282.56|551.76|0.29
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]|726||||726|500.94|551.76|0.29
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]|726||||726|282.56|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|726||||726|145.2|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|726||||726|500.94|551.76|0.29
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]|726||||726|282.56|551.76|0.29
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]|726||||726|363|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|726||||726|363|551.76|0.29
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]|726||||726|363|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|726||||726|500.94|551.76|0.29
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]|726||||726|0|551.76|0.29
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]|726||||726|0|551.76|0.29
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|726||||726|363|551.76|0.29
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AARP [1000]|AARP [100000]|1228.4||||1228.4||933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AETNA [1015]|AETNA [101529]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMBETTER [2930]|AMBETTER [293000]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1228.4||||1228.4|478.09|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1228.4||||1228.4|614.2|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1228.4||||1228.4|478.09|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
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]|1228.4||||1228.4|884.45|933.58|245.68
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]|1228.4||||1228.4|614.2|933.58|245.68
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]|1228.4||||1228.4|614.2|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1228.4||||1228.4|933.58|933.58|245.68
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]|1228.4||||1228.4|478.09|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1228.4||||1228.4|847.6|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA [1260]|CIGNA PPO [126025]|1228.4||||1228.4|491.36|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1228.4||||1228.4||933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1228.4||||1228.4|847.6|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1228.4||||1228.4|614.2|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1228.4||||1228.4|847.6|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1228.4||||1228.4|0|933.58|245.68
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]|1228.4||||1228.4|478.09|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1228.4||||1228.4|0|933.58|245.68
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]|1228.4||||1228.4|478.09|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1228.4||||1228.4|847.6|933.58|245.68
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]|1228.4||||1228.4|478.09|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|Self-pay|Self-pay|1228.4||||1228.4|245.68|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|TML [1980]|TML [198000]|1228.4||||1228.4|847.6|933.58|245.68
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]|1228.4||||1228.4|478.09|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1228.4||||1228.4||933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNICARE [2040]|UNICARE [204000]|1228.4||||1228.4||933.58|245.68
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]|1228.4||||1228.4||933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WEB TPA [2115]|WEB TPA [211500]|1228.4||||1228.4|847.6|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
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]|1228.4||||1228.4|0|933.58|245.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WORKER'S COMP [2125]|TML WC [212537]|1228.4||||1228.4||933.58|245.68
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|770.57||||770.57||585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMBETTER [2930]|AMBETTER [293000]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|770.57||||770.57|385.29|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|554.81|585.63|154.11
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]|770.57||||770.57|385.29|585.63|154.11
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]|770.57||||770.57|385.29|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|770.57||||770.57|585.63|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|770.57||||770.57|531.69|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|770.57||||770.57|308.23|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|770.57||||770.57||585.63|154.11
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]|770.57||||770.57|531.69|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|770.57||||770.57|385.29|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|770.57||||770.57|531.69|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57|531.69|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|770.57||||770.57|154.11|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TML [1980]|TML [198000]|770.57||||770.57|531.69|585.63|154.11
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]|770.57||||770.57|299.91|585.63|154.11
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]|770.57||||770.57||585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNICARE [2040]|UNICARE [204000]|770.57||||770.57||585.63|154.11
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]|770.57||||770.57||585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WEB TPA [2115]|WEB TPA [211500]|770.57||||770.57|531.69|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
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]|770.57||||770.57|0|585.63|154.11
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|770.57||||770.57||585.63|154.11
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|132.93||||132.93||101.03|4.49
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]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.93||||132.93|51.74|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132.93||||132.93|4.49|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132.93||||132.93|51.74|101.03|4.49
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]|132.93||||132.93|0|101.03|4.49
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]|132.93||||132.93|95.71|101.03|4.49
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]|132.93||||132.93|66.47|101.03|4.49
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]|132.93||||132.93|66.47|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132.93||||132.93|101.03|101.03|4.49
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]|132.93||||132.93|51.74|101.03|4.49
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]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132.93||||132.93|91.72|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|132.93||||132.93|53.17|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132.93||||132.93||101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|132.93||||132.93|91.72|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132.93||||132.93|4.49|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132.93||||132.93|91.72|101.03|4.49
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]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.93||||132.93|51.74|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.93||||132.93|0|101.03|4.49
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]|132.93||||132.93|51.74|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|132.93||||132.93|91.72|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.93||||132.93|51.74|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|132.93||||132.93|26.59|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|TML [1980]|TML [198000]|132.93||||132.93|91.72|101.03|4.49
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]|132.93||||132.93|51.74|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.93||||132.93||101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|132.93||||132.93||101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.93||||132.93||101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|132.93||||132.93|91.72|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.93||||132.93|0|101.03|4.49
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]|132.93||||132.93|0|101.03|4.49
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|132.93||||132.93||101.03|4.49
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|81.83||||81.83||62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.83||||81.83|31.85|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.83||||81.83|40.92|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.83||||81.83|31.85|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|58.92|62.19|16.37
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]|81.83||||81.83|40.92|62.19|16.37
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]|81.83||||81.83|40.92|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.83||||81.83|62.19|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.83||||81.83|56.46|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|81.83||||81.83|32.73|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.83||||81.83||62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|81.83||||81.83|56.46|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.83||||81.83|40.92|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.83||||81.83|56.46|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.83||||81.83|31.85|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|81.83||||81.83|56.46|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.83||||81.83|31.85|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|Self-pay|Self-pay|81.83||||81.83|16.37|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|81.83||||81.83|56.46|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.83||||81.83||62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|81.83||||81.83||62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.83||||81.83||62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|81.83||||81.83|56.46|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|81.83||||81.83||62.19|16.37
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AARP [1000]|AARP [100000]|1914||||1914||1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AETNA [1015]|AETNA [101529]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AMBETTER [2930]|AMBETTER [293000]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1914||||1914|744.93|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1914||||1914|0.59|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1914||||1914|744.93|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
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]|1914||||1914|1378.08|1454.64|0.59
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]|1914||||1914|957|1454.64|0.59
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]|1914||||1914|957|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1914||||1914|1454.64|1454.64|0.59
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]|1914||||1914|744.93|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1914||||1914|1320.66|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|CIGNA [1260]|CIGNA PPO [126025]|1914||||1914|765.6|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1914||||1914||1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1914||||1914|1320.66|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1914||||1914|0.59|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1914||||1914|1320.66|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1914||||1914|0|1454.64|0.59
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]|1914||||1914|744.93|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1914||||1914|0|1454.64|0.59
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]|1914||||1914|744.93|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1914||||1914|1320.66|1454.64|0.59
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]|1914||||1914|744.93|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|Self-pay|Self-pay|1914||||1914|382.8|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|TML [1980]|TML [198000]|1914||||1914|1320.66|1454.64|0.59
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]|1914||||1914|744.93|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1914||||1914||1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UNICARE [2040]|UNICARE [204000]|1914||||1914||1454.64|0.59
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]|1914||||1914||1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|WEB TPA [2115]|WEB TPA [211500]|1914||||1914|1320.66|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
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]|1914||||1914|0|1454.64|0.59
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|WORKER'S COMP [2125]|TML WC [212537]|1914||||1914||1454.64|0.59
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|382.28||||382.28|14.96|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382.28||||382.28|275.24|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|382.28||||382.28|290.53|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|382.28||||382.28|152.91|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|382.28||||382.28|14.96|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|382.28||||382.28|76.46|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382.28||||382.28|148.78|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382.28||||382.28|191.14|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|382.28||||382.28|263.77|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382.28||||382.28|0|290.53|14.96
29464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|382.28||||382.28|191.14|290.53|14.96
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AARP [1000]|AARP [100000]|10.46||||10.46||7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA [1015]|AETNA [101529]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMBETTER [2930]|AMBETTER [293000]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.46||||10.46|5.23|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.46||||10.46|7.53|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.46||||10.46|5.23|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.46||||10.46|5.23|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.46||||10.46|7.95|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA [1260]|CIGNA PPO [126025]|10.46||||10.46|4.18|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.46||||10.46||7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.46||||10.46|5.23|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|Self-pay|Self-pay|10.46||||10.46|2.09|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|TML [1980]|TML [198000]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.46||||10.46|4.07|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.46||||10.46||7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNICARE [2040]|UNICARE [204000]|10.46||||10.46||7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.46||||10.46||7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WEB TPA [2115]|WEB TPA [211500]|10.46||||10.46|7.22|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.46||||10.46|0|7.95|2.09
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]|10.46||||10.46|0|7.95|2.09
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WORKER'S COMP [2125]|TML WC [212537]|10.46||||10.46||7.95|2.09
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|63.69||||63.69||48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|63.69||||63.69|31.85|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|63.69||||63.69|24.79|48.4|12.74
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]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.69||||63.69|45.86|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.69||||63.69|31.85|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.69||||63.69|31.85|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|63.69||||63.69|48.4|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|63.69||||63.69|43.95|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|63.69||||63.69|25.48|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|63.69||||63.69||48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|63.69||||63.69|43.95|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|63.69||||63.69|31.85|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|63.69||||63.69|43.95|48.4|12.74
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]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.69||||63.69|0|48.4|12.74
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]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|63.69||||63.69|43.95|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|63.69||||63.69|12.74|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|63.69||||63.69|43.95|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.69||||63.69|24.79|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.69||||63.69||48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|63.69||||63.69||48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.69||||63.69||48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|63.69||||63.69|43.95|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.69||||63.69|0|48.4|12.74
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]|63.69||||63.69|0|48.4|12.74
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|63.69||||63.69||48.4|12.74
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]|4263.6||||4263.6||3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AMBETTER [2930]|AMBETTER [293000]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4263.6||||4263.6|2131.8|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|3069.79|3240.34|852.72
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]|4263.6||||4263.6|2131.8|3240.34|852.72
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]|4263.6||||4263.6|2131.8|3240.34|852.72
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 TRADITIONAL OF TEXAS [115503]|4263.6||||4263.6|3240.34|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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 - GREAT WEST [126009]|4263.6||||4263.6|2941.88|3240.34|852.72
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 PPO [126025]|4263.6||||4263.6|1705.44|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4263.6||||4263.6||3240.34|852.72
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]|4263.6||||4263.6|2941.88|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4263.6||||4263.6|2131.8|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4263.6||||4263.6|2941.88|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6|2941.88|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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|4263.6||||4263.6|852.72|3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|TML [1980]|TML [198000]|4263.6||||4263.6|2941.88|3240.34|852.72
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]|4263.6||||4263.6|1659.39|3240.34|852.72
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]|4263.6||||4263.6||3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UNICARE [2040]|UNICARE [204000]|4263.6||||4263.6||3240.34|852.72
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]|4263.6||||4263.6||3240.34|852.72
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|WEB TPA [2115]|WEB TPA [211500]|4263.6||||4263.6|2941.88|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|4263.6||||4263.6|0|3240.34|852.72
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]|TML WC [212537]|4263.6||||4263.6||3240.34|852.72
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AARP [1000]|AARP [100000]|386.5||||386.5|8|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA [1015]|AETNA [101529]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMBETTER [2930]|AMBETTER [293000]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|386.5||||386.5|12.62|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386.5||||386.5|278.28|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386.5||||386.5|193.25|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386.5||||386.5|193.25|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|386.5||||386.5|293.74|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA [1260]|CIGNA PPO [126025]|386.5||||386.5|28.43|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|386.5||||386.5|8|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|386.5||||386.5|12.62|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|Self-pay|Self-pay|386.5||||386.5|77.3|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|TML [1980]|TML [198000]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386.5||||386.5|12.97|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386.5||||386.5|8|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNICARE [2040]|UNICARE [204000]|386.5||||386.5|8|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386.5||||386.5|8|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WEB TPA [2115]|WEB TPA [211500]|386.5||||386.5|266.69|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386.5||||386.5|0|293.74|8
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WORKER'S COMP [2125]|TML WC [212537]|386.5||||386.5|8|293.74|8
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AARP [1000]|AARP [100000]|1059.84||||1059.84|14.99|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA [1015]|AETNA [101529]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMBETTER [2930]|AMBETTER [293000]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1059.84||||1059.84|193.91|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1059.84||||1059.84|763.08|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1059.84||||1059.84|529.92|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1059.84||||1059.84|529.92|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1059.84||||1059.84|805.48|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA [1260]|CIGNA PPO [126025]|1059.84||||1059.84|77.82|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1059.84||||1059.84|14.99|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1059.84||||1059.84|193.91|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|Self-pay|Self-pay|1059.84||||1059.84|211.97|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|TML [1980]|TML [198000]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1059.84||||1059.84|412.49|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1059.84||||1059.84|14.99|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNICARE [2040]|UNICARE [204000]|1059.84||||1059.84|14.99|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1059.84||||1059.84|14.99|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WEB TPA [2115]|WEB TPA [211500]|1059.84||||1059.84|731.29|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1059.84||||1059.84|0|805.48|14.99
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WORKER'S COMP [2125]|TML WC [212537]|1059.84||||1059.84|14.99|805.48|14.99
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AARP [1000]|AARP [100000]|25||||25||19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AETNA [1015]|AETNA [101529]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AMBETTER [2930]|AMBETTER [293000]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25||||25|12.5|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|18|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|12.5|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25||||25|19|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA [1260]|CIGNA PPO [126025]|25||||25|10|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25||||25||19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25||||25|12.5|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|Self-pay|Self-pay|25||||25|5|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|TML [1980]|TML [198000]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|9.73|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25||19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UNICARE [2040]|UNICARE [204000]|25||||25||19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25||19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WEB TPA [2115]|WEB TPA [211500]|25||||25|17.25|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25|0|19|5
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WORKER'S COMP [2125]|TML WC [212537]|25||||25||19|5
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AARP [1000]|AARP [100000]|185||||185|15.17|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA [1015]|AETNA [101529]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|185||||185|25.1|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|185||||185|133.2|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|185||||185|92.5|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|185||||185|92.5|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|185||||185|140.6|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|185||||185|74|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|185||||185|15.17|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|185||||185|25.1|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|Self-pay|Self-pay|185||||185|37|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|TML [1980]|TML [198000]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|185||||185|72|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|185||||185|15.17|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNICARE [2040]|UNICARE [204000]|185||||185|15.17|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|185||||185|15.17|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|185||||185|127.65|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|185||||185|0|140.6|15.17
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|185||||185|15.17|140.6|15.17
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1166.91||||1166.91||886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1166.91||||1166.91|583.46|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1166.91||||1166.91|840.18|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1166.91||||1166.91|583.46|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1166.91||||1166.91|583.46|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1166.91||||1166.91|886.85|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1166.91||||1166.91|466.76|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1166.91||||1166.91||886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1166.91||||1166.91|583.46|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|Self-pay|Self-pay|1166.91||||1166.91|233.38|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|TML [1980]|TML [198000]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1166.91||||1166.91|454.16|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1166.91||||1166.91||886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1166.91||||1166.91||886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1166.91||||1166.91||886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1166.91||||1166.91|805.17|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1166.91||||1166.91|0|886.85|233.38
30148|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALGANCICLOVIR 450 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1166.91||||1166.91||886.85|233.38
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AARP [1000]|AARP [100000]|236.3||||236.3|6.98|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMBETTER [2930]|AMBETTER [293000]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|236.3||||236.3|11|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236.3||||236.3|170.14|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236.3||||236.3|118.15|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236.3||||236.3|118.15|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|236.3||||236.3|179.59|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|236.3||||236.3|24.79|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|236.3||||236.3|6.98|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|236.3||||236.3|11|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|Self-pay|Self-pay|236.3||||236.3|47.26|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|TML [1980]|TML [198000]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236.3||||236.3|11.3|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236.3||||236.3|6.98|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNICARE [2040]|UNICARE [204000]|236.3||||236.3|6.98|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236.3||||236.3|6.98|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WEB TPA [2115]|WEB TPA [211500]|236.3||||236.3|163.05|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236.3||||236.3|0|179.59|6.98
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|236.3||||236.3|6.98|179.59|6.98
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AARP [1000]|AARP [100000]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA [1015]|AETNA [101529]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMBETTER [2930]|AMBETTER [293000]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|339.19||||339.19|9.11|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|339.19||||339.19|244.22|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|339.19||||339.19|169.6|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|339.19||||339.19|169.6|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|339.19||||339.19|257.78|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|339.19||||339.19|20.56|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|339.19||||339.19|9.11|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|Self-pay|Self-pay|339.19||||339.19|67.84|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|TML [1980]|TML [198000]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNICARE [2040]|UNICARE [204000]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|339.19||||339.19||257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WEB TPA [2115]|WEB TPA [211500]|339.19||||339.19|234.04|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|339.19||||339.19|0|257.78|9.11
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|339.19||||339.19||257.78|9.11
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AARP [1000]|AARP [100000]|421.5||||421.5|8.72|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMBETTER [2930]|AMBETTER [293000]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|421.5||||421.5|13.73|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|421.5||||421.5|303.48|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|421.5||||421.5|210.75|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|421.5||||421.5|210.75|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|421.5||||421.5|320.34|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|421.5||||421.5|30.95|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|421.5||||421.5|8.72|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|421.5||||421.5|13.73|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|Self-pay|Self-pay|421.5||||421.5|84.3|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|TML [1980]|TML [198000]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|421.5||||421.5|14.1|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|421.5||||421.5|8.72|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNICARE [2040]|UNICARE [204000]|421.5||||421.5|8.72|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|421.5||||421.5|8.72|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WEB TPA [2115]|WEB TPA [211500]|421.5||||421.5|290.84|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|421.5||||421.5|0|320.34|8.72
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|421.5||||421.5|8.72|320.34|8.72
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AARP [1000]|AARP [100000]|534||||534|11.05|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA [1015]|AETNA [101529]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMBETTER [2930]|AMBETTER [293000]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|534||||534|17.41|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|534||||534|384.48|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|534||||534|267|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|534||||534|267|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|534||||534|405.84|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA [1260]|CIGNA PPO [126025]|534||||534|38.13|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|534||||534|11.05|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|534||||534|17.41|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|Self-pay|Self-pay|534||||534|106.8|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|TML [1980]|TML [198000]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|534||||534|17.89|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|534||||534|11.05|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNICARE [2040]|UNICARE [204000]|534||||534|11.05|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|534||||534|11.05|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WEB TPA [2115]|WEB TPA [211500]|534||||534|368.46|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|534||||534|0|405.84|11.05
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WORKER'S COMP [2125]|TML WC [212537]|534||||534|11.05|405.84|11.05
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AARP [1000]|AARP [100000]|347.11||||347.11|7.16|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMBETTER [2930]|AMBETTER [293000]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|347.11||||347.11|11.28|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347.11||||347.11|249.92|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347.11||||347.11|173.56|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347.11||||347.11|173.56|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|347.11||||347.11|263.8|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|347.11||||347.11|25.45|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|347.11||||347.11|7.16|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|347.11||||347.11|11.28|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|Self-pay|Self-pay|347.11||||347.11|69.42|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|TML [1980]|TML [198000]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347.11||||347.11|11.59|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347.11||||347.11|7.16|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNICARE [2040]|UNICARE [204000]|347.11||||347.11|7.16|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347.11||||347.11|7.16|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WEB TPA [2115]|WEB TPA [211500]|347.11||||347.11|239.51|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347.11||||347.11|0|263.8|7.16
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|347.11||||347.11|7.16|263.8|7.16
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AARP [1000]|AARP [100000]|2095.08||||2095.08|39.28|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA [1015]|AETNA [101529]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMBETTER [2930]|AMBETTER [293000]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2095.08||||2095.08|61.92|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2095.08||||2095.08|1508.46|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2095.08||||2095.08|1047.54|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2095.08||||2095.08|1047.54|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2095.08||||2095.08|1592.26|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|2095.08||||2095.08|136.84|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2095.08||||2095.08|39.28|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2095.08||||2095.08|61.92|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|Self-pay|Self-pay|2095.08||||2095.08|419.02|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|TML [1980]|TML [198000]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2095.08||||2095.08|63.62|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2095.08||||2095.08|39.28|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNICARE [2040]|UNICARE [204000]|2095.08||||2095.08|39.28|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2095.08||||2095.08|39.28|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WEB TPA [2115]|WEB TPA [211500]|2095.08||||2095.08|1445.61|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2095.08||||2095.08|0|1592.26|39.28
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|2095.08||||2095.08|39.28|1592.26|39.28
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AARP [1000]|AARP [100000]|326.76||||326.76|6.74|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMBETTER [2930]|AMBETTER [293000]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326.76||||326.76|10.62|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326.76||||326.76|235.27|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326.76||||326.76|163.38|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326.76||||326.76|163.38|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326.76||||326.76|248.34|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA [1260]|CIGNA PPO [126025]|326.76||||326.76|23.93|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326.76||||326.76|6.74|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326.76||||326.76|10.62|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|Self-pay|Self-pay|326.76||||326.76|65.35|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|TML [1980]|TML [198000]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326.76||||326.76|10.91|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326.76||||326.76|6.74|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNICARE [2040]|UNICARE [204000]|326.76||||326.76|6.74|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326.76||||326.76|6.74|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WEB TPA [2115]|WEB TPA [211500]|326.76||||326.76|225.46|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326.76||||326.76|0|248.34|6.74
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WORKER'S COMP [2125]|TML WC [212537]|326.76||||326.76|6.74|248.34|6.74
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AARP [1000]|AARP [100000]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA [1015]|AETNA [101529]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMBETTER [2930]|AMBETTER [293000]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|471||||471|19.6|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|471||||471|339.12|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|471||||471|235.5|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|471||||471|235.5|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|471||||471|357.96|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA [1260]|CIGNA PPO [126025]|471||||471|44.19|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|471||||471|19.6|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|Self-pay|Self-pay|471||||471|94.2|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|TML [1980]|TML [198000]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNICARE [2040]|UNICARE [204000]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|471||||471||357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WEB TPA [2115]|WEB TPA [211500]|471||||471|324.99|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|471||||471|0|357.96|19.6
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WORKER'S COMP [2125]|TML WC [212537]|471||||471||357.96|19.6
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AARP [1000]|AARP [100000]|621||||621|14.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA [1015]|AETNA [101529]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMBETTER [2930]|AMBETTER [293000]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|621||||621|23.47|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|621||||621|447.12|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|621||||621|310.5|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|621||||621|310.5|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|621||||621|471.96|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA [1260]|CIGNA PPO [126025]|621||||621|52.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|621||||621|14.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|621||||621|23.47|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|Self-pay|Self-pay|621||||621|124.2|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|TML [1980]|TML [198000]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|621||||621|24.1|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|621||||621|14.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNICARE [2040]|UNICARE [204000]|621||||621|14.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|621||||621|14.89|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WEB TPA [2115]|WEB TPA [211500]|621||||621|428.49|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|621||||621|0|471.96|14.89
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WORKER'S COMP [2125]|TML WC [212537]|621||||621|14.89|471.96|14.89
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AARP [1000]|AARP [100000]|582||||582|10.95|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA [1015]|AETNA [101529]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|582||||582|17.26|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|582||||582|419.04|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|582||||582|291|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|582||||582|291|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|582||||582|442.32|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|582||||582|38.93|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|582||||582|10.95|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|582||||582|17.26|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|Self-pay|Self-pay|582||||582|116.4|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|TML [1980]|TML [198000]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|582||||582|17.74|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|582||||582|10.95|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNICARE [2040]|UNICARE [204000]|582||||582|10.95|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|582||||582|10.95|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|582||||582|401.58|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|582||||582|0|442.32|10.95
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|582||||582|10.95|442.32|10.95
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AARP [1000]|AARP [100000]|424||||424|11.18|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA [1015]|AETNA [101529]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|424||||424|17.6|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|424||||424|305.28|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|424||||424|212|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|424||||424|212|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|424||||424|322.24|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|424||||424|39.72|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|424||||424|11.18|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|424||||424|17.6|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|Self-pay|Self-pay|424||||424|84.8|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|TML [1980]|TML [198000]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|424||||424|18.08|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|424||||424|11.18|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNICARE [2040]|UNICARE [204000]|424||||424|11.18|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|424||||424|11.18|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|424||||424|292.56|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|424||||424|0|322.24|11.18
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|424||||424|11.18|322.24|11.18
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AARP [1000]|AARP [100000]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA [1015]|AETNA [101529]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMBETTER [2930]|AMBETTER [293000]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|513||||513|21.29|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|513||||513|369.36|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|513||||513|256.5|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|513||||513|256.5|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|513||||513|389.88|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA [1260]|CIGNA PPO [126025]|513||||513|48.03|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|513||||513|21.29|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|Self-pay|Self-pay|513||||513|102.6|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|TML [1980]|TML [198000]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNICARE [2040]|UNICARE [204000]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|513||||513||389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WEB TPA [2115]|WEB TPA [211500]|513||||513|353.97|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|513||||513|0|389.88|21.29
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WORKER'S COMP [2125]|TML WC [212537]|513||||513||389.88|21.29
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AARP [1000]|AARP [100000]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AETNA [1015]|AETNA [101529]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AMBETTER [2930]|AMBETTER [293000]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|586.08||||586.08|28.17|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|586.08||||586.08|421.98|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|586.08||||586.08|293.04|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|586.08||||586.08|293.04|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|586.08||||586.08|445.42|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA [1260]|CIGNA PPO [126025]|586.08||||586.08|38.86|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|586.08||||586.08|28.17|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|Self-pay|Self-pay|586.08||||586.08|117.22|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|TML [1980]|TML [198000]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UNICARE [2040]|UNICARE [204000]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|586.08||||586.08||445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WEB TPA [2115]|WEB TPA [211500]|586.08||||586.08|404.4|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|586.08||||586.08|0|445.42|28.17
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WORKER'S COMP [2125]|TML WC [212537]|586.08||||586.08||445.42|28.17
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AARP [1000]|AARP [100000]|785.88||||785.88|10.85|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AETNA [1015]|AETNA [101529]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AMBETTER [2930]|AMBETTER [293000]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|785.88||||785.88|17.23|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|785.88||||785.88|565.83|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|785.88||||785.88|392.94|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|785.88||||785.88|392.94|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|785.88||||785.88|597.27|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA [1260]|CIGNA PPO [126025]|785.88||||785.88|38.86|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|785.88||||785.88|10.85|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|785.88||||785.88|17.23|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|Self-pay|Self-pay|785.88||||785.88|157.18|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|TML [1980]|TML [198000]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|785.88||||785.88|17.7|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785.88||||785.88|10.85|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UNICARE [2040]|UNICARE [204000]|785.88||||785.88|10.85|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785.88||||785.88|10.85|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WEB TPA [2115]|WEB TPA [211500]|785.88||||785.88|542.26|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|785.88||||785.88|0|597.27|10.85
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WORKER'S COMP [2125]|TML WC [212537]|785.88||||785.88|10.85|597.27|10.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AARP [1000]|AARP [100000]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA [1015]|AETNA [101529]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMBETTER [2930]|AMBETTER [293000]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|456.5||||456.5|19.89|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|456.5||||456.5|328.68|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|456.5||||456.5|228.25|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|456.5||||456.5|228.25|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|456.5||||456.5|346.94|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA [1260]|CIGNA PPO [126025]|456.5||||456.5|33.56|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|456.5||||456.5|19.89|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|Self-pay|Self-pay|456.5||||456.5|91.3|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|TML [1980]|TML [198000]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNICARE [2040]|UNICARE [204000]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|456.5||||456.5||346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WEB TPA [2115]|WEB TPA [211500]|456.5||||456.5|314.99|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|456.5||||456.5|0|346.94|19.89
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WORKER'S COMP [2125]|TML WC [212537]|456.5||||456.5||346.94|19.89
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AARP [1000]|AARP [100000]|528.25||||528.25|10.93|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA [1015]|AETNA [101529]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMBETTER [2930]|AMBETTER [293000]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528.25||||528.25|17.23|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528.25||||528.25|380.34|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528.25||||528.25|264.13|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528.25||||528.25|264.13|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528.25||||528.25|401.47|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA [1260]|CIGNA PPO [126025]|528.25||||528.25|38.86|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528.25||||528.25|10.93|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528.25||||528.25|17.23|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|Self-pay|Self-pay|528.25||||528.25|105.65|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|TML [1980]|TML [198000]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528.25||||528.25|17.7|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528.25||||528.25|10.93|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNICARE [2040]|UNICARE [204000]|528.25||||528.25|10.93|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528.25||||528.25|10.93|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WEB TPA [2115]|WEB TPA [211500]|528.25||||528.25|364.49|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528.25||||528.25|0|401.47|10.93
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WORKER'S COMP [2125]|TML WC [212537]|528.25||||528.25|10.93|401.47|10.93
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AARP [1000]|AARP [100000]|546.75||||546.75|11.32|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA [1015]|AETNA [101529]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMBETTER [2930]|AMBETTER [293000]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|546.75||||546.75|17.85|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546.75||||546.75|393.66|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546.75||||546.75|273.38|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546.75||||546.75|273.38|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|546.75||||546.75|415.53|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA [1260]|CIGNA PPO [126025]|546.75||||546.75|40.25|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|546.75||||546.75|11.32|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|546.75||||546.75|17.85|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|Self-pay|Self-pay|546.75||||546.75|109.35|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|TML [1980]|TML [198000]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546.75||||546.75|18.33|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546.75||||546.75|11.32|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNICARE [2040]|UNICARE [204000]|546.75||||546.75|11.32|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546.75||||546.75|11.32|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WEB TPA [2115]|WEB TPA [211500]|546.75||||546.75|377.26|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546.75||||546.75|0|415.53|11.32
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WORKER'S COMP [2125]|TML WC [212537]|546.75||||546.75|11.32|415.53|11.32
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AARP [1000]|AARP [100000]|442||||442|11.67|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AETNA [1015]|AETNA [101529]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AMBETTER [2930]|AMBETTER [293000]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|442||||442|18.38|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|442||||442|318.24|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|442||||442|221|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|442||||442|221|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|442||||442|335.92|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA [1260]|CIGNA PPO [126025]|442||||442|41.47|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|442||||442|11.67|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|442||||442|18.38|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|Self-pay|Self-pay|442||||442|88.4|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|TML [1980]|TML [198000]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|442||||442|18.89|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|442||||442|11.67|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UNICARE [2040]|UNICARE [204000]|442||||442|11.67|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|442||||442|11.67|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WEB TPA [2115]|WEB TPA [211500]|442||||442|304.98|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|442||||442|0|335.92|11.67
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WORKER'S COMP [2125]|TML WC [212537]|442||||442|11.67|335.92|11.67
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AARP [1000]|AARP [100000]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA [1015]|AETNA [101529]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMBETTER [2930]|AMBETTER [293000]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|504||||504|20.97|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|504||||504|362.88|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|504||||504|252|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|504||||504|252|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|504||||504|383.04|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA [1260]|CIGNA PPO [126025]|504||||504|47.23|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|504||||504|20.97|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|Self-pay|Self-pay|504||||504|100.8|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|TML [1980]|TML [198000]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNICARE [2040]|UNICARE [204000]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|504||||504||383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WEB TPA [2115]|WEB TPA [211500]|504||||504|347.76|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|504||||504|0|383.04|20.97
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WORKER'S COMP [2125]|TML WC [212537]|504||||504||383.04|20.97
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AARP [1000]|AARP [100000]|540||||540|11.18|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA [1015]|AETNA [101529]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMBETTER [2930]|AMBETTER [293000]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|540||||540|17.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|540||||540|388.8|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|540||||540|270|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|540||||540|270|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|540||||540|410.4|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA [1260]|CIGNA PPO [126025]|540||||540|39.72|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|540||||540|11.18|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|540||||540|17.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|Self-pay|Self-pay|540||||540|108|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|TML [1980]|TML [198000]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|540||||540|18.08|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|540||||540|11.18|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNICARE [2040]|UNICARE [204000]|540||||540|11.18|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|540||||540|11.18|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WEB TPA [2115]|WEB TPA [211500]|540||||540|372.6|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|540||||540|0|410.4|11.18
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WORKER'S COMP [2125]|TML WC [212537]|540||||540|11.18|410.4|11.18
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AARP [1000]|AARP [100000]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA [1015]|AETNA [101529]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMBETTER [2930]|AMBETTER [293000]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|785.88||||785.88|24.23|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|785.88||||785.88|565.83|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|785.88||||785.88|392.94|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|785.88||||785.88|392.94|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|785.88||||785.88|597.27|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA [1260]|CIGNA PPO [126025]|785.88||||785.88|40.15|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|785.88||||785.88|24.23|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|Self-pay|Self-pay|785.88||||785.88|157.18|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|TML [1980]|TML [198000]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNICARE [2040]|UNICARE [204000]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785.88||||785.88||597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WEB TPA [2115]|WEB TPA [211500]|785.88||||785.88|542.26|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|785.88||||785.88|0|597.27|24.23
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WORKER'S COMP [2125]|TML WC [212537]|785.88||||785.88||597.27|24.23
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AARP [1000]|AARP [100000]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA [1015]|AETNA [101529]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMBETTER [2930]|AMBETTER [293000]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|281.25||||281.25|10.62|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|281.25||||281.25|202.5|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|281.25||||281.25|140.63|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|281.25||||281.25|140.63|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|281.25||||281.25|213.75|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA [1260]|CIGNA PPO [126025]|281.25||||281.25|23.93|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|281.25||||281.25|10.62|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|Self-pay|Self-pay|281.25||||281.25|56.25|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|TML [1980]|TML [198000]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNICARE [2040]|UNICARE [204000]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|281.25||||281.25||213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WEB TPA [2115]|WEB TPA [211500]|281.25||||281.25|194.06|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|281.25||||281.25|0|213.75|10.62
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WORKER'S COMP [2125]|TML WC [212537]|281.25||||281.25||213.75|10.62
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AARP [1000]|AARP [100000]|1382||||1382|31.86|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA [1015]|AETNA [101529]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMBETTER [2930]|AMBETTER [293000]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1382||||1382|50.21|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1382||||1382|995.04|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1382||||1382|691|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1382||||1382|691|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1382||||1382|1050.32|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA [1260]|CIGNA PPO [126025]|1382||||1382|113.2|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1382||||1382|31.86|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1382||||1382|50.21|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|Self-pay|Self-pay|1382||||1382|276.4|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|TML [1980]|TML [198000]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1382||||1382|51.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1382||||1382|31.86|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNICARE [2040]|UNICARE [204000]|1382||||1382|31.86|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1382||||1382|31.86|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WEB TPA [2115]|WEB TPA [211500]|1382||||1382|953.58|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1382||||1382|0|1050.32|31.86
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WORKER'S COMP [2125]|TML WC [212537]|1382||||1382|31.86|1050.32|31.86
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AARP [1000]|AARP [100000]|104||||104|4.08|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA [1015]|AETNA [101529]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|6.44|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|74.88|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|52|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|79.04|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|14.5|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104|4.08|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|6.44|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|Self-pay|Self-pay|104||||104|20.8|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|TML [1980]|TML [198000]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|6.61|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|4.08|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNICARE [2040]|UNICARE [204000]|104||||104|4.08|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|4.08|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|0|79.04|4.08
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104|4.08|79.04|4.08
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AARP [1000]|AARP [100000]|104||||104|4.27|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA [1015]|AETNA [101529]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|10.11|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|74.88|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|52|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|79.04|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|15.16|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104|4.27|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|10.11|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|Self-pay|Self-pay|104||||104|20.8|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|TML [1980]|TML [198000]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|10.4|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|4.27|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNICARE [2040]|UNICARE [204000]|104||||104|4.27|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|4.27|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|0|79.04|4.27
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104|4.27|79.04|4.27
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AARP [1000]|AARP [100000]|386.5||||386.5|8|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA [1015]|AETNA [101529]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMBETTER [2930]|AMBETTER [293000]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|386.5||||386.5|12.62|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386.5||||386.5|278.28|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386.5||||386.5|193.25|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386.5||||386.5|193.25|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|386.5||||386.5|293.74|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA [1260]|CIGNA PPO [126025]|386.5||||386.5|28.43|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|386.5||||386.5|8|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|386.5||||386.5|12.62|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|Self-pay|Self-pay|386.5||||386.5|77.3|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|TML [1980]|TML [198000]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386.5||||386.5|12.97|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386.5||||386.5|8|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNICARE [2040]|UNICARE [204000]|386.5||||386.5|8|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386.5||||386.5|8|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WEB TPA [2115]|WEB TPA [211500]|386.5||||386.5|266.69|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386.5||||386.5|0|293.74|8
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WORKER'S COMP [2125]|TML WC [212537]|386.5||||386.5|8|293.74|8
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AARP [1000]|AARP [100000]|1390.5||||1390.5|33.61|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA [1015]|AETNA [101529]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMBETTER [2930]|AMBETTER [293000]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1390.5||||1390.5|52.98|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1390.5||||1390.5|1001.16|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1390.5||||1390.5|695.25|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1390.5||||1390.5|695.25|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1390.5||||1390.5|1056.78|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA [1260]|CIGNA PPO [126025]|1390.5||||1390.5|119.42|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1390.5||||1390.5|33.61|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1390.5||||1390.5|52.98|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|Self-pay|Self-pay|1390.5||||1390.5|278.1|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|TML [1980]|TML [198000]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1390.5||||1390.5|54.43|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1390.5||||1390.5|33.61|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNICARE [2040]|UNICARE [204000]|1390.5||||1390.5|33.61|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1390.5||||1390.5|33.61|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WEB TPA [2115]|WEB TPA [211500]|1390.5||||1390.5|959.45|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1390.5||||1390.5|0|1056.78|33.61
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WORKER'S COMP [2125]|TML WC [212537]|1390.5||||1390.5|33.61|1056.78|33.61
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AARP [1000]|AARP [100000]|372||||372|13.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMBETTER [2930]|AMBETTER [293000]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|372||||372|21.8|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|372||||372|267.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|372||||372|186|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|372||||372|186|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|372||||372|282.72|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|372||||372|49.15|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|372||||372|13.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|372||||372|21.8|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|Self-pay|Self-pay|372||||372|74.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|TML [1980]|TML [198000]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|372||||372|22.4|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|372||||372|13.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNICARE [2040]|UNICARE [204000]|372||||372|13.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|372||||372|13.84|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WEB TPA [2115]|WEB TPA [211500]|372||||372|256.68|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|372||||372|0|282.72|13.84
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|372||||372|13.84|282.72|13.84
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AARP [1000]|AARP [100000]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AETNA [1015]|AETNA [101529]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AMBETTER [2930]|AMBETTER [293000]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|672||||672|29.87|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|672||||672|483.84|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|672||||672|336|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|672||||672|336|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|672||||672|510.72|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA [1260]|CIGNA PPO [126025]|672||||672|49.45|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|672||||672|29.87|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|Self-pay|Self-pay|672||||672|134.4|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|TML [1980]|TML [198000]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UNICARE [2040]|UNICARE [204000]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|672||||672||510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WEB TPA [2115]|WEB TPA [211500]|672||||672|463.68|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|672||||672|0|510.72|29.87
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WORKER'S COMP [2125]|TML WC [212537]|672||||672||510.72|29.87
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AARP [1000]|AARP [100000]|580.75||||580.75|12.02|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA [1015]|AETNA [101529]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMBETTER [2930]|AMBETTER [293000]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|580.75||||580.75|18.94|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580.75||||580.75|418.14|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580.75||||580.75|290.38|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580.75||||580.75|290.38|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|580.75||||580.75|441.37|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA [1260]|CIGNA PPO [126025]|580.75||||580.75|42.7|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|580.75||||580.75|12.02|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|580.75||||580.75|18.94|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|Self-pay|Self-pay|580.75||||580.75|116.15|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|TML [1980]|TML [198000]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580.75||||580.75|19.46|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580.75||||580.75|12.02|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNICARE [2040]|UNICARE [204000]|580.75||||580.75|12.02|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580.75||||580.75|12.02|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WEB TPA [2115]|WEB TPA [211500]|580.75||||580.75|400.72|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580.75||||580.75|0|441.37|12.02
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WORKER'S COMP [2125]|TML WC [212537]|580.75||||580.75|12.02|441.37|12.02
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AARP [1000]|AARP [100000]|131||||131|5.35|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA [1015]|AETNA [101529]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMBETTER [2930]|AMBETTER [293000]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131||||131|8.42|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131||||131|94.32|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131||||131|65.5|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131||||131|65.5|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131||||131|99.56|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA [1260]|CIGNA PPO [126025]|131||||131|19|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131||||131|5.35|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131||||131|8.42|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|Self-pay|Self-pay|131||||131|26.2|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|TML [1980]|TML [198000]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131||||131|8.65|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131||||131|5.35|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNICARE [2040]|UNICARE [204000]|131||||131|5.35|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131||||131|5.35|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WEB TPA [2115]|WEB TPA [211500]|131||||131|90.39|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131||||131|0|99.56|5.35
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WORKER'S COMP [2125]|TML WC [212537]|131||||131|5.35|99.56|5.35
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AARP [1000]|AARP [100000]|581.5||||581.5|12.04|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA [1015]|AETNA [101529]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMBETTER [2930]|AMBETTER [293000]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|581.5||||581.5|18.98|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|581.5||||581.5|418.68|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|581.5||||581.5|290.75|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|581.5||||581.5|290.75|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|581.5||||581.5|441.94|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA [1260]|CIGNA PPO [126025]|581.5||||581.5|42.8|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|581.5||||581.5|12.04|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|581.5||||581.5|18.98|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|Self-pay|Self-pay|581.5||||581.5|116.3|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|TML [1980]|TML [198000]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|581.5||||581.5|19.49|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|581.5||||581.5|12.04|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNICARE [2040]|UNICARE [204000]|581.5||||581.5|12.04|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|581.5||||581.5|12.04|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WEB TPA [2115]|WEB TPA [211500]|581.5||||581.5|401.24|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|581.5||||581.5|0|441.94|12.04
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WORKER'S COMP [2125]|TML WC [212537]|581.5||||581.5|12.04|441.94|12.04
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AARP [1000]|AARP [100000]|101||||101|4.14|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA [1015]|AETNA [101529]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMBETTER [2930]|AMBETTER [293000]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101||||101|6.53|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101||||101|72.72|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101||||101|50.5|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101||||101|50.5|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|101||||101|76.76|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA [1260]|CIGNA PPO [126025]|101||||101|14.7|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101||||101|4.14|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101||||101|6.53|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|Self-pay|Self-pay|101||||101|20.2|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|TML [1980]|TML [198000]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101||||101|6.71|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101||||101|4.14|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNICARE [2040]|UNICARE [204000]|101||||101|4.14|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101||||101|4.14|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WEB TPA [2115]|WEB TPA [211500]|101||||101|69.69|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101||||101|0|76.76|4.14
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WORKER'S COMP [2125]|TML WC [212537]|101||||101|4.14|76.76|4.14
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AARP [1000]|AARP [100000]|129.5||||129.5|2.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA [1015]|AETNA [101529]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMBETTER [2930]|AMBETTER [293000]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|129.5||||129.5|5.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.5||||129.5|93.24|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.5||||129.5|64.75|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.5||||129.5|64.75|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|129.5||||129.5|98.42|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA [1260]|CIGNA PPO [126025]|129.5||||129.5|9.53|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|129.5||||129.5|2.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|129.5||||129.5|5.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|Self-pay|Self-pay|129.5||||129.5|25.9|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|TML [1980]|TML [198000]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.5||||129.5|5.85|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.5||||129.5|2.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNICARE [2040]|UNICARE [204000]|129.5||||129.5|2.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.5||||129.5|2.69|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WEB TPA [2115]|WEB TPA [211500]|129.5||||129.5|89.36|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.5||||129.5|0|98.42|2.69
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WORKER'S COMP [2125]|TML WC [212537]|129.5||||129.5|2.69|98.42|2.69
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AARP [1000]|AARP [100000]|1082.5||||1082.5|24.42|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA [1015]|AETNA [101529]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMBETTER [2930]|AMBETTER [293000]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1082.5||||1082.5|38.48|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1082.5||||1082.5|779.4|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1082.5||||1082.5|541.25|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1082.5||||1082.5|541.25|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1082.5||||1082.5|822.7|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA [1260]|CIGNA PPO [126025]|1082.5||||1082.5|86.76|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1082.5||||1082.5|24.42|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1082.5||||1082.5|38.48|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|Self-pay|Self-pay|1082.5||||1082.5|216.5|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|TML [1980]|TML [198000]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1082.5||||1082.5|39.53|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1082.5||||1082.5|24.42|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNICARE [2040]|UNICARE [204000]|1082.5||||1082.5|24.42|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1082.5||||1082.5|24.42|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WEB TPA [2115]|WEB TPA [211500]|1082.5||||1082.5|746.93|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1082.5||||1082.5|0|822.7|24.42
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WORKER'S COMP [2125]|TML WC [212537]|1082.5||||1082.5|24.42|822.7|24.42
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AARP [1000]|AARP [100000]|104||||104|4.25|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA [1015]|AETNA [101529]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|104||||104|6.71|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|74.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|52|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|104||||104|79.04|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|104||||104|15.13|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|104||||104|4.25|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|104||||104|6.71|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|Self-pay|Self-pay|104||||104|20.8|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|TML [1980]|TML [198000]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|6.88|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|4.25|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNICARE [2040]|UNICARE [204000]|104||||104|4.25|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|4.25|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|104||||104|71.76|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|0|79.04|4.25
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|104||||104|4.25|79.04|4.25
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AARP [1000]|AARP [100000]|276||||276|11.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA [1015]|AETNA [101529]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMBETTER [2930]|AMBETTER [293000]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|276||||276|17.78|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|276||||276|198.72|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|276||||276|138|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|276||||276|138|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|276||||276|209.76|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA [1260]|CIGNA PPO [126025]|276||||276|40.08|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|276||||276|11.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|276||||276|17.78|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|Self-pay|Self-pay|276||||276|55.2|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|TML [1980]|TML [198000]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|276||||276|18.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|276||||276|11.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNICARE [2040]|UNICARE [204000]|276||||276|11.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|276||||276|11.27|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WEB TPA [2115]|WEB TPA [211500]|276||||276|190.44|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|276||||276|0|209.76|11.27
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WORKER'S COMP [2125]|TML WC [212537]|276||||276|11.27|209.76|11.27
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AARP [1000]|AARP [100000]|755.5||||755.5|15.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA [1015]|AETNA [101529]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMBETTER [2930]|AMBETTER [293000]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|755.5||||755.5|24.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|755.5||||755.5|543.96|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|755.5||||755.5|377.75|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|755.5||||755.5|377.75|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|755.5||||755.5|574.18|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA [1260]|CIGNA PPO [126025]|755.5||||755.5|55.61|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|755.5||||755.5|15.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|755.5||||755.5|24.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|Self-pay|Self-pay|755.5||||755.5|151.1|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|TML [1980]|TML [198000]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|755.5||||755.5|25.33|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|755.5||||755.5|15.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNICARE [2040]|UNICARE [204000]|755.5||||755.5|15.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|755.5||||755.5|15.65|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WEB TPA [2115]|WEB TPA [211500]|755.5||||755.5|521.3|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|755.5||||755.5|0|574.18|15.65
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WORKER'S COMP [2125]|TML WC [212537]|755.5||||755.5|15.65|574.18|15.65
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AARP [1000]|AARP [100000]|217||||217|8.86|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA [1015]|AETNA [101529]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMBETTER [2930]|AMBETTER [293000]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|217||||217|13.96|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217|156.24|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217|108.5|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217|108.5|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|217||||217|164.92|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA [1260]|CIGNA PPO [126025]|217||||217|31.48|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|217||||217|8.86|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|217||||217|13.96|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|Self-pay|Self-pay|217||||217|43.4|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|TML [1980]|TML [198000]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|14.34|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217|8.86|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNICARE [2040]|UNICARE [204000]|217||||217|8.86|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217|8.86|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WEB TPA [2115]|WEB TPA [211500]|217||||217|149.73|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217|0|164.92|8.86
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WORKER'S COMP [2125]|TML WC [212537]|217||||217|8.86|164.92|8.86
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AARP [1000]|AARP [100000]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA [1015]|AETNA [101529]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|563||||563|18.36|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|563||||563|405.36|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|563||||563|281.5|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|563||||563|281.5|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|563||||563|427.88|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|563||||563|41.41|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|563||||563|18.36|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|Self-pay|Self-pay|563||||563|112.6|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|TML [1980]|TML [198000]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNICARE [2040]|UNICARE [204000]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|563||||563||427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|563||||563|388.47|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|563||||563|0|427.88|18.36
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|563||||563||427.88|18.36
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AARP [1000]|AARP [100000]|93||||93|3.79|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA [1015]|AETNA [101529]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|5.98|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|66.96|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|46.5|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|70.68|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|13.47|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93|3.79|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|5.98|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|Self-pay|Self-pay|93||||93|18.6|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|TML [1980]|TML [198000]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|6.14|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|3.79|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNICARE [2040]|UNICARE [204000]|93||||93|3.79|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|3.79|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|0|70.68|3.79
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93|3.79|70.68|3.79
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AARP [1000]|AARP [100000]|174||||174|3.59|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA [1015]|AETNA [101529]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|174||||174|5.66|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174||||174|125.28|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174||||174|87|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174||||174|87|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|174||||174|132.24|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|174||||174|12.74|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|174||||174|3.59|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|174||||174|5.66|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|Self-pay|Self-pay|174||||174|34.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|TML [1980]|TML [198000]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174||||174|5.8|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174||||174|3.59|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNICARE [2040]|UNICARE [204000]|174||||174|3.59|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174||||174|3.59|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|174||||174|120.06|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174||||174|0|132.24|3.59
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|174||||174|3.59|132.24|3.59
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AARP [1000]|AARP [100000]|494.5||||494.5|10.24|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA [1015]|AETNA [101529]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMBETTER [2930]|AMBETTER [293000]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|494.5||||494.5|16.13|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|494.5||||494.5|356.04|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|494.5||||494.5|247.25|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|494.5||||494.5|247.25|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|494.5||||494.5|375.82|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA [1260]|CIGNA PPO [126025]|494.5||||494.5|36.38|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|494.5||||494.5|10.24|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|494.5||||494.5|16.13|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|Self-pay|Self-pay|494.5||||494.5|98.9|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|TML [1980]|TML [198000]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|494.5||||494.5|16.57|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|494.5||||494.5|10.24|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNICARE [2040]|UNICARE [204000]|494.5||||494.5|10.24|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|494.5||||494.5|10.24|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WEB TPA [2115]|WEB TPA [211500]|494.5||||494.5|341.21|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|494.5||||494.5|0|375.82|10.24
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WORKER'S COMP [2125]|TML WC [212537]|494.5||||494.5|10.24|375.82|10.24
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AARP [1000]|AARP [100000]|649.75||||649.75|13.45|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA [1015]|AETNA [101529]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|649.75||||649.75|21.19|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|649.75||||649.75|467.82|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|649.75||||649.75|324.88|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|649.75||||649.75|324.88|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|649.75||||649.75|493.81|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|649.75||||649.75|47.8|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|649.75||||649.75|13.45|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|649.75||||649.75|21.19|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|Self-pay|Self-pay|649.75||||649.75|129.95|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|TML [1980]|TML [198000]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|649.75||||649.75|21.77|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|649.75||||649.75|13.45|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNICARE [2040]|UNICARE [204000]|649.75||||649.75|13.45|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|649.75||||649.75|13.45|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|649.75||||649.75|448.33|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|649.75||||649.75|0|493.81|13.45
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|649.75||||649.75|13.45|493.81|13.45
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AARP [1000]|AARP [100000]|259.75||||259.75|5.37|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA [1015]|AETNA [101529]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMBETTER [2930]|AMBETTER [293000]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|259.75||||259.75|8.46|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259.75||||259.75|187.02|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259.75||||259.75|129.88|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259.75||||259.75|129.88|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|259.75||||259.75|197.41|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA [1260]|CIGNA PPO [126025]|259.75||||259.75|19.1|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|259.75||||259.75|5.37|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|259.75||||259.75|8.46|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|Self-pay|Self-pay|259.75||||259.75|51.95|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|TML [1980]|TML [198000]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259.75||||259.75|8.7|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259.75||||259.75|5.37|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNICARE [2040]|UNICARE [204000]|259.75||||259.75|5.37|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259.75||||259.75|5.37|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WEB TPA [2115]|WEB TPA [211500]|259.75||||259.75|179.23|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259.75||||259.75|0|197.41|5.37
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WORKER'S COMP [2125]|TML WC [212537]|259.75||||259.75|5.37|197.41|5.37
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AARP [1000]|AARP [100000]|159||||159|11.05|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AETNA [1015]|AETNA [101529]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AMBETTER [2930]|AMBETTER [293000]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|159||||159|17.41|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|159||||159|114.48|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|159||||159|79.5|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|159||||159|79.5|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|159||||159|120.84|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA [1260]|CIGNA PPO [126025]|159||||159|39.26|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|159||||159|11.05|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|GROUP PENSION ADMIN [1450]|GPA [145000]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|159||||159|17.41|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|PHCS [1780]|PHCS MULTIPLAN [178000]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|Self-pay|Self-pay|159||||159|31.8|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|TML [1980]|TML [198000]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|159||||159|17.89|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|159||||159|11.05|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UNICARE [2040]|UNICARE [204000]|159||||159|11.05|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|159||||159|11.05|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WEB TPA [2115]|WEB TPA [211500]|159||||159|109.71|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|159||||159|0|120.84|11.05
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WORKER'S COMP [2125]|TML WC [212537]|159||||159|11.05|120.84|11.05
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AARP [1000]|AARP [100000]|245.25||||245.25|9.52|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AETNA [1015]|AETNA [101529]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AMBETTER [2930]|AMBETTER [293000]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|245.25||||245.25|15.02|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245.25||||245.25|176.58|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245.25||||245.25|122.63|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245.25||||245.25|122.63|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|245.25||||245.25|186.39|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|245.25||||245.25|33.83|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|245.25||||245.25|9.52|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|245.25||||245.25|15.02|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|Self-pay|Self-pay|245.25||||245.25|49.05|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|TML [1980]|TML [198000]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245.25||||245.25|15.42|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245.25||||245.25|9.52|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UNICARE [2040]|UNICARE [204000]|245.25||||245.25|9.52|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245.25||||245.25|9.52|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WEB TPA [2115]|WEB TPA [211500]|245.25||||245.25|169.22|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245.25||||245.25|0|186.39|9.52
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|245.25||||245.25|9.52|186.39|9.52
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AARP [1000]|AARP [100000]|103||||103|4.22|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA [1015]|AETNA [101529]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMBETTER [2930]|AMBETTER [293000]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103||||103|6.66|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103||||103|74.16|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103||||103|51.5|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103||||103|51.5|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103||||103|78.28|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA [1260]|CIGNA PPO [126025]|103||||103|15.03|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103||||103|4.22|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103||||103|6.66|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|Self-pay|Self-pay|103||||103|20.6|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|TML [1980]|TML [198000]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103||||103|6.84|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103||||103|4.22|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNICARE [2040]|UNICARE [204000]|103||||103|4.22|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103||||103|4.22|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WEB TPA [2115]|WEB TPA [211500]|103||||103|71.07|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103||||103|0|78.28|4.22
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WORKER'S COMP [2125]|TML WC [212537]|103||||103|4.22|78.28|4.22
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AARP [1000]|AARP [100000]|45||||45|4.27|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|45||||45|6.73|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45||||45|32.4|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45||||45|22.5|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45||||45|22.5|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|45||||45|34.2|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|45||||45|15.16|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|45||||45|4.27|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|45||||45|6.73|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|Self-pay|Self-pay|45||||45|9|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|TML [1980]|TML [198000]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45||||45|6.92|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45||||45|4.27|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|45||||45|4.27|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45||||45|4.27|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|45||||45|31.05|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45||||45|0|34.2|4.27
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|45||||45|4.27|34.2|4.27
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AARP [1000]|AARP [100000]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA [1015]|AETNA [101529]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMBETTER [2930]|AMBETTER [293000]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|130||||130|8.41|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130||||130|93.6|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130||||130|65|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130||||130|65|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|130||||130|98.8|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA [1260]|CIGNA PPO [126025]|130||||130|18.97|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|130||||130|8.41|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|Self-pay|Self-pay|130||||130|26|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|TML [1980]|TML [198000]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNICARE [2040]|UNICARE [204000]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130||||130||98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WEB TPA [2115]|WEB TPA [211500]|130||||130|89.7|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130||||130|0|98.8|8.41
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WORKER'S COMP [2125]|TML WC [212537]|130||||130||98.8|8.41
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AARP [1000]|AARP [100000]|600.5||||600.5|12.43|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA [1015]|AETNA [101529]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMBETTER [2930]|AMBETTER [293000]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|600.5||||600.5|19.6|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600.5||||600.5|432.36|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600.5||||600.5|300.25|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600.5||||600.5|300.25|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|600.5||||600.5|456.38|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA [1260]|CIGNA PPO [126025]|600.5||||600.5|44.19|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|600.5||||600.5|12.43|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|600.5||||600.5|19.6|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|Self-pay|Self-pay|600.5||||600.5|120.1|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|TML [1980]|TML [198000]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600.5||||600.5|20.15|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600.5||||600.5|12.43|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNICARE [2040]|UNICARE [204000]|600.5||||600.5|12.43|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600.5||||600.5|12.43|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WEB TPA [2115]|WEB TPA [211500]|600.5||||600.5|414.35|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600.5||||600.5|0|456.38|12.43
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WORKER'S COMP [2125]|TML WC [212537]|600.5||||600.5|12.43|456.38|12.43
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AARP [1000]|AARP [100000]|1381.75||||1381.75|31.75|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA [1015]|AETNA [101529]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMBETTER [2930]|AMBETTER [293000]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1381.75||||1381.75|50.05|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1381.75||||1381.75|994.86|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1381.75||||1381.75|690.88|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1381.75||||1381.75|690.88|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1381.75||||1381.75|1050.13|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA [1260]|CIGNA PPO [126025]|1381.75||||1381.75|112.84|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1381.75||||1381.75|31.75|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1381.75||||1381.75|50.05|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|Self-pay|Self-pay|1381.75||||1381.75|276.35|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|TML [1980]|TML [198000]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1381.75||||1381.75|51.42|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1381.75||||1381.75|31.75|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNICARE [2040]|UNICARE [204000]|1381.75||||1381.75|31.75|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1381.75||||1381.75|31.75|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WEB TPA [2115]|WEB TPA [211500]|1381.75||||1381.75|953.41|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1381.75||||1381.75|0|1050.13|31.75
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WORKER'S COMP [2125]|TML WC [212537]|1381.75||||1381.75|31.75|1050.13|31.75
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AARP [1000]|AARP [100000]|749.25||||749.25|15.5|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA [1015]|AETNA [101529]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMBETTER [2930]|AMBETTER [293000]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|749.25||||749.25|24.43|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|749.25||||749.25|539.46|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|749.25||||749.25|374.63|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|749.25||||749.25|374.63|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|749.25||||749.25|569.43|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA [1260]|CIGNA PPO [126025]|749.25||||749.25|55.08|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|749.25||||749.25|15.5|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|749.25||||749.25|24.43|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|Self-pay|Self-pay|749.25||||749.25|149.85|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|TML [1980]|TML [198000]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|749.25||||749.25|25.09|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|749.25||||749.25|15.5|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNICARE [2040]|UNICARE [204000]|749.25||||749.25|15.5|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|749.25||||749.25|15.5|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WEB TPA [2115]|WEB TPA [211500]|749.25||||749.25|516.98|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|749.25||||749.25|0|569.43|15.5
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WORKER'S COMP [2125]|TML WC [212537]|749.25||||749.25|15.5|569.43|15.5
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AARP [1000]|AARP [100000]|542.25||||542.25|11.24|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA [1015]|AETNA [101529]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMBETTER [2930]|AMBETTER [293000]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|542.25||||542.25|17.72|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|542.25||||542.25|390.42|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|542.25||||542.25|271.13|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|542.25||||542.25|271.13|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|542.25||||542.25|412.11|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA [1260]|CIGNA PPO [126025]|542.25||||542.25|39.95|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|542.25||||542.25|11.24|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|542.25||||542.25|17.72|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|Self-pay|Self-pay|542.25||||542.25|108.45|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|TML [1980]|TML [198000]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|542.25||||542.25|18.21|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|542.25||||542.25|11.24|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNICARE [2040]|UNICARE [204000]|542.25||||542.25|11.24|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|542.25||||542.25|11.24|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WEB TPA [2115]|WEB TPA [211500]|542.25||||542.25|374.15|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|542.25||||542.25|0|412.11|11.24
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WORKER'S COMP [2125]|TML WC [212537]|542.25||||542.25|11.24|412.11|11.24
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AARP [1000]|AARP [100000]|585.75||||585.75|12.13|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA [1015]|AETNA [101529]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMBETTER [2930]|AMBETTER [293000]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|585.75||||585.75|19.11|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|585.75||||585.75|421.74|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|585.75||||585.75|292.88|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|585.75||||585.75|292.88|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|585.75||||585.75|445.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|585.75||||585.75|43.1|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|585.75||||585.75|12.13|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|585.75||||585.75|19.11|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|Self-pay|Self-pay|585.75||||585.75|117.15|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|TML [1980]|TML [198000]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|585.75||||585.75|19.64|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|585.75||||585.75|12.13|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNICARE [2040]|UNICARE [204000]|585.75||||585.75|12.13|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|585.75||||585.75|12.13|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WEB TPA [2115]|WEB TPA [211500]|585.75||||585.75|404.17|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|585.75||||585.75|0|445.17|12.13
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|585.75||||585.75|12.13|445.17|12.13
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AARP [1000]|AARP [100000]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AETNA [1015]|AETNA [101529]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AMBETTER [2930]|AMBETTER [293000]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|384||||384|22.95|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|384||||384|276.48|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|384||||384|192|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|384||||384|192|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|384||||384|291.84|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA [1260]|CIGNA PPO [126025]|384||||384|50.74|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|384||||384|22.95|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|Self-pay|Self-pay|384||||384|76.8|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|TML [1980]|TML [198000]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UNICARE [2040]|UNICARE [204000]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|384||||384||291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WEB TPA [2115]|WEB TPA [211500]|384||||384|264.96|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|384||||384|0|291.84|22.95
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WORKER'S COMP [2125]|TML WC [212537]|384||||384||291.84|22.95
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AARP [1000]|AARP [100000]|370.75||||370.75|7.67|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA [1015]|AETNA [101529]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMBETTER [2930]|AMBETTER [293000]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|370.75||||370.75|12.09|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|370.75||||370.75|266.94|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|370.75||||370.75|185.38|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|370.75||||370.75|185.38|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|370.75||||370.75|281.77|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA [1260]|CIGNA PPO [126025]|370.75||||370.75|27.27|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|370.75||||370.75|7.67|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|370.75||||370.75|12.09|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|Self-pay|Self-pay|370.75||||370.75|74.15|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|TML [1980]|TML [198000]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|370.75||||370.75|12.42|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|370.75||||370.75|7.67|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNICARE [2040]|UNICARE [204000]|370.75||||370.75|7.67|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|370.75||||370.75|7.67|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WEB TPA [2115]|WEB TPA [211500]|370.75||||370.75|255.82|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|370.75||||370.75|0|281.77|7.67
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WORKER'S COMP [2125]|TML WC [212537]|370.75||||370.75|7.67|281.77|7.67
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AARP [1000]|AARP [100000]|365||||365|13.58|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA [1015]|AETNA [101529]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMBETTER [2930]|AMBETTER [293000]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|365||||365|21.4|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|365||||365|262.8|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|365||||365|182.5|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|365||||365|182.5|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|365||||365|277.4|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA [1260]|CIGNA PPO [126025]|365||||365|48.26|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|365||||365|13.58|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|365||||365|21.4|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|Self-pay|Self-pay|365||||365|73|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|TML [1980]|TML [198000]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|365||||365|21.99|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|365||||365|13.58|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNICARE [2040]|UNICARE [204000]|365||||365|13.58|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|365||||365|13.58|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WEB TPA [2115]|WEB TPA [211500]|365||||365|251.85|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|365||||365|0|277.4|13.58
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WORKER'S COMP [2125]|TML WC [212537]|365||||365|13.58|277.4|13.58
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AARP [1000]|AARP [100000]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AETNA [1015]|AETNA [101529]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AMBETTER [2930]|AMBETTER [293000]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|167||||167|10.43|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|167||||167|120.24|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|167||||167|83.5|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|167||||167|83.5|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|167||||167|126.92|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA [1260]|CIGNA PPO [126025]|167||||167|23.5|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|167||||167|10.43|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|Self-pay|Self-pay|167||||167|33.4|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|TML [1980]|TML [198000]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UNICARE [2040]|UNICARE [204000]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167||||167||126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WEB TPA [2115]|WEB TPA [211500]|167||||167|115.23|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|167||||167|0|126.92|10.43
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WORKER'S COMP [2125]|TML WC [212537]|167||||167||126.92|10.43
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AARP [1000]|AARP [100000]|693||||693|15.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA [1015]|AETNA [101529]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMBETTER [2930]|AMBETTER [293000]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|693||||693|33.89|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|693||||693|34.82|526.68|15.96
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]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|693||||693|498.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|693||||693|346.5|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|693||||693|346.5|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|693||||693|526.68|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|693||||693|478.17|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA [1260]|CIGNA PPO [126025]|693||||693|56.7|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|693||||693|15.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|GROUP PENSION ADMIN [1450]|GPA [145000]|693||||693|478.17|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|693||||693|33.89|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|693||||693|478.17|526.68|15.96
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]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|693||||693|0|526.68|15.96
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]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|PHCS [1780]|PHCS MULTIPLAN [178000]|693||||693|478.17|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|Self-pay|Self-pay|693||||693|138.6|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|TML [1980]|TML [198000]|693||||693|478.17|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|693||||693|34.82|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|693||||693|15.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNICARE [2040]|UNICARE [204000]|693||||693|15.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|693||||693|15.96|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WEB TPA [2115]|WEB TPA [211500]|693||||693|478.17|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|693||||693|0|526.68|15.96
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]|693||||693|0|526.68|15.96
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WORKER'S COMP [2125]|TML WC [212537]|693||||693|15.96|526.68|15.96
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AARP [1000]|AARP [100000]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AETNA [1015]|AETNA [101529]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AMBETTER [2930]|AMBETTER [293000]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|244||||244|17.34|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|175.68|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|122|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|122|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|244||||244|185.44|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|CIGNA [1260]|CIGNA PPO [126025]|244||||244|29.29|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|244||||244|17.34|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|Self-pay|Self-pay|244||||244|48.8|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|TML [1980]|TML [198000]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|UNICARE [2040]|UNICARE [204000]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|WEB TPA [2115]|WEB TPA [211500]|244||||244|168.36|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244|0|185.44|17.34
30182820|EAP|0301 - LABORATORY-CHEMISTRY|HC  HGB-O2 AFFINITY PO2 50% SATURATION OXYGEN|1|WORKER'S COMP [2125]|TML WC [212537]|244||||244||185.44|17.34
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AARP [1000]|AARP [100000]|79||||79|3.23|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AETNA [1015]|AETNA [101529]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AMBETTER [2930]|AMBETTER [293000]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79||||79|5.11|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79||||79|56.88|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79||||79|39.5|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79||||79|39.5|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79||||79|60.04|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA [1260]|CIGNA PPO [126025]|79||||79|11.52|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79||||79|3.23|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79||||79|5.11|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|Self-pay|Self-pay|79||||79|15.8|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|TML [1980]|TML [198000]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79||||79|5.25|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79||||79|3.23|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UNICARE [2040]|UNICARE [204000]|79||||79|3.23|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79||||79|3.23|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WEB TPA [2115]|WEB TPA [211500]|79||||79|54.51|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79||||79|0|60.04|3.23
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WORKER'S COMP [2125]|TML WC [212537]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AARP [1000]|AARP [100000]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA [1015]|AETNA [101529]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMBETTER [2930]|AMBETTER [293000]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79||||79|5.11|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79||||79|56.88|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79||||79|39.5|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79||||79|39.5|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79||||79|60.04|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA [1260]|CIGNA PPO [126025]|79||||79|11.52|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79||||79|5.11|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|Self-pay|Self-pay|79||||79|15.8|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|TML [1980]|TML [198000]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79||||79|5.25|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNICARE [2040]|UNICARE [204000]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79||||79|3.23|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WEB TPA [2115]|WEB TPA [211500]|79||||79|54.51|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79||||79|0|60.04|3.23
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WORKER'S COMP [2125]|TML WC [212537]|79||||79|3.23|60.04|3.23
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AARP [1000]|AARP [100000]|57||||57|1.93|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA [1015]|AETNA [101529]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|57||||57|4.26|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57||||57|41.04|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57||||57|28.5|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57||||57|28.5|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|57||||57|43.32|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|57||||57|6.85|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|57||||57|1.93|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|57||||57|4.26|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|Self-pay|Self-pay|57||||57|11.4|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|TML [1980]|TML [198000]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57||||57|22.18|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57||||57|1.93|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNICARE [2040]|UNICARE [204000]|57||||57|1.93|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57||||57|1.93|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|57||||57|39.33|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57||||57|0|43.32|1.93
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|57||||57|1.93|43.32|1.93
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AARP [1000]|AARP [100000]|286.75||||286.75|5.94|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA [1015]|AETNA [101529]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMBETTER [2930]|AMBETTER [293000]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|286.75||||286.75|9.36|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|286.75||||286.75|206.46|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|286.75||||286.75|143.38|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|286.75||||286.75|143.38|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|286.75||||286.75|217.93|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA [1260]|CIGNA PPO [126025]|286.75||||286.75|21.12|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|286.75||||286.75|5.94|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|286.75||||286.75|9.36|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|Self-pay|Self-pay|286.75||||286.75|57.35|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|TML [1980]|TML [198000]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|286.75||||286.75|9.62|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|286.75||||286.75|5.94|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNICARE [2040]|UNICARE [204000]|286.75||||286.75|5.94|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|286.75||||286.75|5.94|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WEB TPA [2115]|WEB TPA [211500]|286.75||||286.75|197.86|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|286.75||||286.75|0|217.93|5.94
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WORKER'S COMP [2125]|TML WC [212537]|286.75||||286.75|5.94|217.93|5.94
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AARP [1000]|AARP [100000]|501.25||||501.25|10.37|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA [1015]|AETNA [101529]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMBETTER [2930]|AMBETTER [293000]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|501.25||||501.25|16.35|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|501.25||||501.25|360.9|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|501.25||||501.25|250.63|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|501.25||||501.25|250.63|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|501.25||||501.25|380.95|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA [1260]|CIGNA PPO [126025]|501.25||||501.25|36.84|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|501.25||||501.25|10.37|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|501.25||||501.25|16.35|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|Self-pay|Self-pay|501.25||||501.25|100.25|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|TML [1980]|TML [198000]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|501.25||||501.25|16.81|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|501.25||||501.25|10.37|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNICARE [2040]|UNICARE [204000]|501.25||||501.25|10.37|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|501.25||||501.25|10.37|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WEB TPA [2115]|WEB TPA [211500]|501.25||||501.25|345.86|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|501.25||||501.25|0|380.95|10.37
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WORKER'S COMP [2125]|TML WC [212537]|501.25||||501.25|10.37|380.95|10.37
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AARP [1000]|AARP [100000]|513||||513|10.61|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA [1015]|AETNA [101529]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMBETTER [2930]|AMBETTER [293000]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|513||||513|16.73|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|513||||513|369.36|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|513||||513|256.5|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|513||||513|256.5|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|513||||513|389.88|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA [1260]|CIGNA PPO [126025]|513||||513|37.7|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|513||||513|10.61|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|513||||513|16.73|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|Self-pay|Self-pay|513||||513|102.6|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|TML [1980]|TML [198000]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|513||||513|17.19|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|513||||513|10.61|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNICARE [2040]|UNICARE [204000]|513||||513|10.61|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|513||||513|10.61|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WEB TPA [2115]|WEB TPA [211500]|513||||513|353.97|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|513||||513|0|389.88|10.61
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WORKER'S COMP [2125]|TML WC [212537]|513||||513|10.61|389.88|10.61
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AARP [1000]|AARP [100000]|386.5||||386.5|8|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA [1015]|AETNA [101529]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMBETTER [2930]|AMBETTER [293000]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|386.5||||386.5|12.62|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386.5||||386.5|278.28|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386.5||||386.5|193.25|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386.5||||386.5|193.25|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|386.5||||386.5|293.74|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA [1260]|CIGNA PPO [126025]|386.5||||386.5|28.43|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|386.5||||386.5|8|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|386.5||||386.5|12.62|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|Self-pay|Self-pay|386.5||||386.5|77.3|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|TML [1980]|TML [198000]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386.5||||386.5|12.97|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386.5||||386.5|8|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNICARE [2040]|UNICARE [204000]|386.5||||386.5|8|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386.5||||386.5|8|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WEB TPA [2115]|WEB TPA [211500]|386.5||||386.5|266.69|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386.5||||386.5|0|293.74|8
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WORKER'S COMP [2125]|TML WC [212537]|386.5||||386.5|8|293.74|8
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AARP [1000]|AARP [100000]|443.25||||443.25|9.52|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA [1015]|AETNA [101529]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMBETTER [2930]|AMBETTER [293000]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|443.25||||443.25|14.99|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|443.25||||443.25|319.14|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|443.25||||443.25|221.63|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|443.25||||443.25|221.63|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|443.25||||443.25|336.87|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA PPO [126025]|443.25||||443.25|33.8|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|443.25||||443.25|9.52|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|443.25||||443.25|14.99|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|Self-pay|Self-pay|443.25||||443.25|88.65|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|TML [1980]|TML [198000]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|443.25||||443.25|15.41|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|443.25||||443.25|9.52|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNICARE [2040]|UNICARE [204000]|443.25||||443.25|9.52|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|443.25||||443.25|9.52|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WEB TPA [2115]|WEB TPA [211500]|443.25||||443.25|305.84|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|443.25||||443.25|0|336.87|9.52
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TML WC [212537]|443.25||||443.25|9.52|336.87|9.52
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AARP [1000]|AARP [100000]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|23.92|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|344.34|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|239.13|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|239.13|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|363.47|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|39.59|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|23.92|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|Self-pay|Self-pay|478.25||||478.25|95.65|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25|0|363.47|23.92
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||363.47|23.92
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AARP [1000]|AARP [100000]|215.4||||215.4|10.68|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA [1015]|AETNA [101529]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMBETTER [2930]|AMBETTER [293000]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|215.4||||215.4|22.45|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215.4||||215.4|155.09|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215.4||||215.4|107.7|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215.4||||215.4|107.7|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|215.4||||215.4|163.7|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA [1260]|CIGNA PPO [126025]|215.4||||215.4|37.93|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|215.4||||215.4|10.68|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|215.4||||215.4|22.45|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|Self-pay|Self-pay|215.4||||215.4|43.08|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|TML [1980]|TML [198000]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215.4||||215.4|23.07|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215.4||||215.4|10.68|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNICARE [2040]|UNICARE [204000]|215.4||||215.4|10.68|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215.4||||215.4|10.68|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WEB TPA [2115]|WEB TPA [211500]|215.4||||215.4|148.63|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215.4||||215.4|0|163.7|10.68
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WORKER'S COMP [2125]|TML WC [212537]|215.4||||215.4|10.68|163.7|10.68
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AARP [1000]|AARP [100000]|455.25||||455.25|9.43|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA [1015]|AETNA [101529]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|455.25||||455.25|14.86|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|455.25||||455.25|327.78|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|455.25||||455.25|227.63|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|455.25||||455.25|227.63|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|455.25||||455.25|345.99|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|455.25||||455.25|33.5|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|455.25||||455.25|9.43|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|455.25||||455.25|14.86|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|Self-pay|Self-pay|455.25||||455.25|91.05|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|TML [1980]|TML [198000]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|455.25||||455.25|15.26|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|455.25||||455.25|9.43|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNICARE [2040]|UNICARE [204000]|455.25||||455.25|9.43|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|455.25||||455.25|9.43|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|455.25||||455.25|314.12|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|455.25||||455.25|0|345.99|9.43
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|455.25||||455.25|9.43|345.99|9.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AARP [1000]|AARP [100000]|131||||131|5.34|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA [1015]|AETNA [101529]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMBETTER [2930]|AMBETTER [293000]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131||||131|8.41|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131||||131|94.32|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131||||131|65.5|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131||||131|65.5|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131||||131|99.56|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA [1260]|CIGNA PPO [126025]|131||||131|18.97|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131||||131|5.34|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131||||131|8.41|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|Self-pay|Self-pay|131||||131|26.2|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|TML [1980]|TML [198000]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131||||131|8.63|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131||||131|5.34|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNICARE [2040]|UNICARE [204000]|131||||131|5.34|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131||||131|5.34|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WEB TPA [2115]|WEB TPA [211500]|131||||131|90.39|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131||||131|0|99.56|5.34
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WORKER'S COMP [2125]|TML WC [212537]|131||||131|5.34|99.56|5.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AARP [1000]|AARP [100000]|177||||177|7.21|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA [1015]|AETNA [101529]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMBETTER [2930]|AMBETTER [293000]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|177||||177|11.36|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|177||||177|127.44|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|177||||177|88.5|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|177||||177|88.5|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|177||||177|134.52|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA [1260]|CIGNA PPO [126025]|177||||177|25.62|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|177||||177|7.21|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|177||||177|11.36|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|Self-pay|Self-pay|177||||177|35.4|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|TML [1980]|TML [198000]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|177||||177|11.67|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|177||||177|7.21|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNICARE [2040]|UNICARE [204000]|177||||177|7.21|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|177||||177|7.21|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WEB TPA [2115]|WEB TPA [211500]|177||||177|122.13|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|177||||177|0|134.52|7.21
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WORKER'S COMP [2125]|TML WC [212537]|177||||177|7.21|134.52|7.21
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AARP [1000]|AARP [100000]|425.5||||425.5|8.81|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA [1015]|AETNA [101529]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMBETTER [2930]|AMBETTER [293000]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|425.5||||425.5|15.04|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|425.5||||425.5|306.36|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|425.5||||425.5|212.75|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|425.5||||425.5|212.75|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|425.5||||425.5|323.38|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA [1260]|CIGNA PPO [126025]|425.5||||425.5|31.31|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|425.5||||425.5|8.81|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|425.5||||425.5|15.04|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|Self-pay|Self-pay|425.5||||425.5|85.1|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|TML [1980]|TML [198000]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|425.5||||425.5|15.45|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|425.5||||425.5|8.81|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNICARE [2040]|UNICARE [204000]|425.5||||425.5|8.81|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|425.5||||425.5|8.81|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WEB TPA [2115]|WEB TPA [211500]|425.5||||425.5|293.6|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|425.5||||425.5|0|323.38|8.81
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WORKER'S COMP [2125]|TML WC [212537]|425.5||||425.5|8.81|323.38|8.81
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AARP [1000]|AARP [100000]|122||||122|4.98|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA [1015]|AETNA [101529]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMBETTER [2930]|AMBETTER [293000]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|122||||122|7.85|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|87.84|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|61|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|61|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|122||||122|92.72|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA [1260]|CIGNA PPO [126025]|122||||122|17.68|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|122||||122|4.98|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|122||||122|7.85|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|Self-pay|Self-pay|122||||122|24.4|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|TML [1980]|TML [198000]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122|8.06|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122|4.98|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNICARE [2040]|UNICARE [204000]|122||||122|4.98|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122|4.98|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WEB TPA [2115]|WEB TPA [211500]|122||||122|84.18|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122|0|92.72|4.98
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WORKER'S COMP [2125]|TML WC [212537]|122||||122|4.98|92.72|4.98
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AARP [1000]|AARP [100000]|139||||139|5.68|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA [1015]|AETNA [101529]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMBETTER [2930]|AMBETTER [293000]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139||||139|8.96|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139||||139|100.08|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139||||139|69.5|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139||||139|69.5|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139||||139|105.64|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA [1260]|CIGNA PPO [126025]|139||||139|20.19|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139||||139|5.68|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139||||139|8.96|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|Self-pay|Self-pay|139||||139|27.8|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|TML [1980]|TML [198000]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139||||139|9.21|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139||||139|5.68|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNICARE [2040]|UNICARE [204000]|139||||139|5.68|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139||||139|5.68|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WEB TPA [2115]|WEB TPA [211500]|139||||139|95.91|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139||||139|0|105.64|5.68
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WORKER'S COMP [2125]|TML WC [212537]|139||||139|5.68|105.64|5.68
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AARP [1000]|AARP [100000]|267.25||||267.25|5.53|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA [1015]|AETNA [101529]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMBETTER [2930]|AMBETTER [293000]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|267.25||||267.25|8.71|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|267.25||||267.25|192.42|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|267.25||||267.25|133.63|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|267.25||||267.25|133.63|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|267.25||||267.25|203.11|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA [1260]|CIGNA PPO [126025]|267.25||||267.25|19.63|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|267.25||||267.25|5.53|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|267.25||||267.25|8.71|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|Self-pay|Self-pay|267.25||||267.25|53.45|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|TML [1980]|TML [198000]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|267.25||||267.25|8.95|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|267.25||||267.25|5.53|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNICARE [2040]|UNICARE [204000]|267.25||||267.25|5.53|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|267.25||||267.25|5.53|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WEB TPA [2115]|WEB TPA [211500]|267.25||||267.25|184.4|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|267.25||||267.25|0|203.11|5.53
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WORKER'S COMP [2125]|TML WC [212537]|267.25||||267.25|5.53|203.11|5.53
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AARP [1000]|AARP [100000]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA [1015]|AETNA [101529]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMBETTER [2930]|AMBETTER [293000]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|514.5||||514.5|16.8|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|514.5||||514.5|370.44|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|514.5||||514.5|257.25|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|514.5||||514.5|257.25|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|514.5||||514.5|391.02|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA [1260]|CIGNA PPO [126025]|514.5||||514.5|37.83|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|514.5||||514.5|16.8|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|Self-pay|Self-pay|514.5||||514.5|102.9|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|TML [1980]|TML [198000]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNICARE [2040]|UNICARE [204000]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|514.5||||514.5||391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WEB TPA [2115]|WEB TPA [211500]|514.5||||514.5|355.01|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|514.5||||514.5|0|391.02|16.8
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WORKER'S COMP [2125]|TML WC [212537]|514.5||||514.5||391.02|16.8
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AARP [1000]|AARP [100000]|516||||516|28|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA [1015]|AETNA [101529]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMBETTER [2930]|AMBETTER [293000]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|516||||516|51.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|516||||516|371.52|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|516||||516|258|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|516||||516|258|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|516||||516|392.16|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA [1260]|CIGNA PPO [126025]|516||||516|99.5|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|516||||516|28|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|516||||516|51.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|Self-pay|Self-pay|516||||516|103.2|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|TML [1980]|TML [198000]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|516||||516|52.44|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|516||||516|28|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNICARE [2040]|UNICARE [204000]|516||||516|28|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|516||||516|28|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WEB TPA [2115]|WEB TPA [211500]|516||||516|356.04|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|516||||516|0|392.16|28
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WORKER'S COMP [2125]|TML WC [212537]|516||||516|28|392.16|28
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AARP [1000]|AARP [100000]|541.5||||541.5|11.21|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA [1015]|AETNA [101529]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMBETTER [2930]|AMBETTER [293000]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|541.5||||541.5|17.68|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|541.5||||541.5|389.88|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|541.5||||541.5|270.75|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|541.5||||541.5|270.75|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|541.5||||541.5|411.54|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA [1260]|CIGNA PPO [126025]|541.5||||541.5|39.85|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|541.5||||541.5|11.21|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|541.5||||541.5|17.68|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|Self-pay|Self-pay|541.5||||541.5|108.3|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|TML [1980]|TML [198000]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|541.5||||541.5|18.16|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|541.5||||541.5|11.21|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNICARE [2040]|UNICARE [204000]|541.5||||541.5|11.21|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|541.5||||541.5|11.21|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WEB TPA [2115]|WEB TPA [211500]|541.5||||541.5|373.64|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|541.5||||541.5|0|411.54|11.21
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WORKER'S COMP [2125]|TML WC [212537]|541.5||||541.5|11.21|411.54|11.21
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AARP [1000]|AARP [100000]|656||||656|13.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA [1015]|AETNA [101529]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMBETTER [2930]|AMBETTER [293000]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|656||||656|27.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|656||||656|472.32|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|656||||656|328|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|656||||656|328|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|656||||656|498.56|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA [1260]|CIGNA PPO [126025]|656||||656|48.23|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|656||||656|13.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|656||||656|27.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|Self-pay|Self-pay|656||||656|131.2|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|TML [1980]|TML [198000]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|656||||656|28.33|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|656||||656|13.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNICARE [2040]|UNICARE [204000]|656||||656|13.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|656||||656|13.57|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WEB TPA [2115]|WEB TPA [211500]|656||||656|452.64|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|656||||656|0|498.56|13.57
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WORKER'S COMP [2125]|TML WC [212537]|656||||656|13.57|498.56|13.57
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AARP [1000]|AARP [100000]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA [1015]|AETNA [101529]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMBETTER [2930]|AMBETTER [293000]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|196.25||||196.25|8.59|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|196.25||||196.25|141.3|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|196.25||||196.25|98.13|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|196.25||||196.25|98.13|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|196.25||||196.25|149.15|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA [1260]|CIGNA PPO [126025]|196.25||||196.25|19.4|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|196.25||||196.25|8.59|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|Self-pay|Self-pay|196.25||||196.25|39.25|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|TML [1980]|TML [198000]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNICARE [2040]|UNICARE [204000]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|196.25||||196.25||149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WEB TPA [2115]|WEB TPA [211500]|196.25||||196.25|135.41|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|196.25||||196.25|0|149.15|8.59
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WORKER'S COMP [2125]|TML WC [212537]|196.25||||196.25||149.15|8.59
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AARP [1000]|AARP [100000]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA [1015]|AETNA [101529]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMBETTER [2930]|AMBETTER [293000]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99||||99|8.87|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|71.28|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|49.5|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99||||99|75.24|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA [1260]|CIGNA PPO [126025]|99||||99|19.99|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99||||99|8.87|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|Self-pay|Self-pay|99||||99|19.8|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|TML [1980]|TML [198000]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNICARE [2040]|UNICARE [204000]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WEB TPA [2115]|WEB TPA [211500]|99||||99|68.31|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99|0|75.24|8.87
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WORKER'S COMP [2125]|TML WC [212537]|99||||99||75.24|8.87
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AARP [1000]|AARP [100000]|775||||775|34.04|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA [1015]|AETNA [101529]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMBETTER [2930]|AMBETTER [293000]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|775||||775|53.66|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|775||||775|558|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|775||||775|387.5|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|775||||775|387.5|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|775||||775|589|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA [1260]|CIGNA PPO [126025]|775||||775|120.98|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|775||||775|34.04|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|775||||775|53.66|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|Self-pay|Self-pay|775||||775|155|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|TML [1980]|TML [198000]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|775||||775|55.14|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|775||||775|34.04|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNICARE [2040]|UNICARE [204000]|775||||775|34.04|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|775||||775|34.04|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WEB TPA [2115]|WEB TPA [211500]|775||||775|534.75|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|775||||775|0|589|34.04
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WORKER'S COMP [2125]|TML WC [212537]|775||||775|34.04|589|34.04
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AARP [1000]|AARP [100000]|142.25||||142.25|2.95|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AETNA [1015]|AETNA [101529]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AMBETTER [2930]|AMBETTER [293000]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|142.25||||142.25|4.65|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.25||||142.25|102.42|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.25||||142.25|71.13|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.25||||142.25|71.13|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|142.25||||142.25|108.11|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA [1260]|CIGNA PPO [126025]|142.25||||142.25|10.49|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|142.25||||142.25|2.95|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|142.25||||142.25|4.65|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|Self-pay|Self-pay|142.25||||142.25|28.45|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|TML [1980]|TML [198000]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.25||||142.25|4.79|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.25||||142.25|2.95|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UNICARE [2040]|UNICARE [204000]|142.25||||142.25|2.95|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.25||||142.25|2.95|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WEB TPA [2115]|WEB TPA [211500]|142.25||||142.25|98.15|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.25||||142.25|0|108.11|2.95
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WORKER'S COMP [2125]|TML WC [212537]|142.25||||142.25|2.95|108.11|2.95
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AARP [1000]|AARP [100000]|206||||206|4.27|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AETNA [1015]|AETNA [101529]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AMBETTER [2930]|AMBETTER [293000]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|206||||206|6.73|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|206||||206|148.32|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|206||||206|103|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|206||||206|103|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|206||||206|156.56|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA [1260]|CIGNA PPO [126025]|206||||206|15.16|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|206||||206|4.27|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|206||||206|6.73|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|Self-pay|Self-pay|206||||206|41.2|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|TML [1980]|TML [198000]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|206||||206|6.92|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|206||||206|4.27|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UNICARE [2040]|UNICARE [204000]|206||||206|4.27|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|206||||206|4.27|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WEB TPA [2115]|WEB TPA [211500]|206||||206|142.14|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|206||||206|0|156.56|4.27
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WORKER'S COMP [2125]|TML WC [212537]|206||||206|4.27|156.56|4.27
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AARP [1000]|AARP [100000]|189.25||||189.25|3.91|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|6.16|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|136.26|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|94.63|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|94.63|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|143.83|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.9|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25|3.91|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|6.16|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|Self-pay|Self-pay|189.25||||189.25|37.85|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25|6.33|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25|3.91|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25|3.91|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25|3.91|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.25||||189.25|0|143.83|3.91
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25|3.91|143.83|3.91
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AARP [1000]|AARP [100000]|93||||93|3.79|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA [1015]|AETNA [101529]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMBETTER [2930]|AMBETTER [293000]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|93||||93|6.19|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|66.96|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|46.5|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|93||||93|70.68|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|93||||93|13.47|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|93||||93|3.79|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|93||||93|6.19|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|Self-pay|Self-pay|93||||93|18.6|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|TML [1980]|TML [198000]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|6.36|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|3.79|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNICARE [2040]|UNICARE [204000]|93||||93|3.79|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|3.79|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WEB TPA [2115]|WEB TPA [211500]|93||||93|64.17|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|0|70.68|3.79
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|93||||93|3.79|70.68|3.79
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AARP [1000]|AARP [100000]|336.25||||336.25|12.03|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA [1015]|AETNA [101529]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMBETTER [2930]|AMBETTER [293000]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|336.25||||336.25|18.97|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336.25||||336.25|242.1|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336.25||||336.25|168.13|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336.25||||336.25|168.13|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|336.25||||336.25|255.55|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA [1260]|CIGNA PPO [126025]|336.25||||336.25|42.77|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|336.25||||336.25|12.03|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|336.25||||336.25|18.97|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|Self-pay|Self-pay|336.25||||336.25|67.25|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|TML [1980]|TML [198000]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336.25||||336.25|19.49|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336.25||||336.25|12.03|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNICARE [2040]|UNICARE [204000]|336.25||||336.25|12.03|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336.25||||336.25|12.03|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WEB TPA [2115]|WEB TPA [211500]|336.25||||336.25|232.01|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336.25||||336.25|0|255.55|12.03
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WORKER'S COMP [2125]|TML WC [212537]|336.25||||336.25|12.03|255.55|12.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AARP [1000]|AARP [100000]|958.25||||958.25|22.09|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA [1015]|AETNA [101529]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMBETTER [2930]|AMBETTER [293000]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|958.25||||958.25|35.39|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|958.25||||958.25|689.94|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|958.25||||958.25|479.13|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|958.25||||958.25|479.13|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|958.25||||958.25|728.27|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA [1260]|CIGNA PPO [126025]|958.25||||958.25|78.51|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|958.25||||958.25|22.09|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|958.25||||958.25|35.39|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|Self-pay|Self-pay|958.25||||958.25|191.65|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|TML [1980]|TML [198000]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|958.25||||958.25|36.35|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|958.25||||958.25|22.09|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNICARE [2040]|UNICARE [204000]|958.25||||958.25|22.09|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|958.25||||958.25|22.09|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WEB TPA [2115]|WEB TPA [211500]|958.25||||958.25|661.19|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|958.25||||958.25|0|728.27|22.09
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WORKER'S COMP [2125]|TML WC [212537]|958.25||||958.25|22.09|728.27|22.09
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AARP [1000]|AARP [100000]|732.75||||732.75|15.17|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA [1015]|AETNA [101529]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|732.75||||732.75|23.91|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|732.75||||732.75|527.58|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|732.75||||732.75|366.38|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|732.75||||732.75|366.38|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|732.75||||732.75|556.89|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|732.75||||732.75|53.92|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|732.75||||732.75|15.17|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|732.75||||732.75|23.91|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|Self-pay|Self-pay|732.75||||732.75|146.55|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|TML [1980]|TML [198000]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|732.75||||732.75|24.57|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|732.75||||732.75|15.17|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNICARE [2040]|UNICARE [204000]|732.75||||732.75|15.17|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|732.75||||732.75|15.17|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|732.75||||732.75|505.6|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|732.75||||732.75|0|556.89|15.17
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|732.75||||732.75|15.17|556.89|15.17
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AARP [1000]|AARP [100000]|74||||74|3.02|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMBETTER [2930]|AMBETTER [293000]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|74||||74|4.77|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74||||74|53.28|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74||||74|37|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74||||74|37|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|74||||74|56.24|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|74||||74|10.76|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|74||||74|3.02|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|74||||74|4.77|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|Self-pay|Self-pay|74||||74|14.8|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|TML [1980]|TML [198000]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74||||74|4.9|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74||||74|3.02|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNICARE [2040]|UNICARE [204000]|74||||74|3.02|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74||||74|3.02|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WEB TPA [2115]|WEB TPA [211500]|74||||74|51.06|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74||||74|0|56.24|3.02
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|74||||74|3.02|56.24|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AARP [1000]|AARP [100000]|48||||48|3.02|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA [1015]|AETNA [101529]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMBETTER [2930]|AMBETTER [293000]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48||||48|4.77|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48||||48|34.56|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48||||48|24|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48||||48|24|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48||||48|36.48|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA [1260]|CIGNA PPO [126025]|48||||48|10.76|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48||||48|3.02|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48||||48|4.77|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|Self-pay|Self-pay|48||||48|9.6|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|TML [1980]|TML [198000]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48||||48|4.9|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48||||48|3.02|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNICARE [2040]|UNICARE [204000]|48||||48|3.02|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48||||48|3.02|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WEB TPA [2115]|WEB TPA [211500]|48||||48|33.12|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48||||48|0|36.48|3.02
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WORKER'S COMP [2125]|TML WC [212537]|48||||48|3.02|36.48|3.02
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AARP [1000]|AARP [100000]|12||||12|3.02|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA [1015]|AETNA [101529]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMBETTER [2930]|AMBETTER [293000]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12||||12|5.2|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12||||12|8.64|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12||||12|6|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12||||12|6|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12||||12|9.12|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA [1260]|CIGNA PPO [126025]|12||||12|10.76|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12||||12|3.02|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12||||12|5.2|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|Self-pay|Self-pay|12||||12|2.4|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|TML [1980]|TML [198000]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12||||12|5.34|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12||||12|3.02|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNICARE [2040]|UNICARE [204000]|12||||12|3.02|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12||||12|3.02|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WEB TPA [2115]|WEB TPA [211500]|12||||12|8.28|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12||||12|0|10.76|2.4
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WORKER'S COMP [2125]|TML WC [212537]|12||||12|3.02|10.76|2.4
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AARP [1000]|AARP [100000]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AETNA [1015]|AETNA [101529]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AMBETTER [2930]|AMBETTER [293000]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|23.18|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|105.12|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|73|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|110.96|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|52.26|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|23.18|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|Self-pay|Self-pay|146||||146|29.2|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|TML [1980]|TML [198000]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UNICARE [2040]|UNICARE [204000]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146|0|110.96|23.18
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146||110.96|23.18
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AARP [1000]|AARP [100000]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA [1015]|AETNA [101529]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMBETTER [2930]|AMBETTER [293000]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|691.25||||691.25|37.97|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|691.25||||691.25|497.7|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|691.25||||691.25|345.63|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|691.25||||691.25|345.63|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|691.25||||691.25|525.35|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA [1260]|CIGNA PPO [126025]|691.25||||691.25|52.76|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|691.25||||691.25|37.97|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|Self-pay|Self-pay|691.25||||691.25|138.25|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|TML [1980]|TML [198000]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNICARE [2040]|UNICARE [204000]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|691.25||||691.25||525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WEB TPA [2115]|WEB TPA [211500]|691.25||||691.25|476.96|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|691.25||||691.25|0|525.35|37.97
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WORKER'S COMP [2125]|TML WC [212537]|691.25||||691.25||525.35|37.97
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AARP [1000]|AARP [100000]|876.75||||876.75|18.14|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA [1015]|AETNA [101529]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMBETTER [2930]|AMBETTER [293000]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|876.75||||876.75|28.59|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|876.75||||876.75|631.26|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|876.75||||876.75|438.38|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|876.75||||876.75|438.38|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|876.75||||876.75|666.33|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA [1260]|CIGNA PPO [126025]|876.75||||876.75|64.45|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|876.75||||876.75|18.14|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|876.75||||876.75|28.59|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|Self-pay|Self-pay|876.75||||876.75|175.35|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|TML [1980]|TML [198000]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|876.75||||876.75|29.37|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|876.75||||876.75|18.14|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNICARE [2040]|UNICARE [204000]|876.75||||876.75|18.14|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|876.75||||876.75|18.14|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WEB TPA [2115]|WEB TPA [211500]|876.75||||876.75|604.96|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|876.75||||876.75|0|666.33|18.14
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WORKER'S COMP [2125]|TML WC [212537]|876.75||||876.75|18.14|666.33|18.14
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AARP [1000]|AARP [100000]|97||||97|3.97|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA [1015]|AETNA [101529]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMBETTER [2930]|AMBETTER [293000]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|6.25|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|69.84|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|48.5|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|48.5|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|73.72|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|14.1|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97|3.97|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|6.25|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|Self-pay|Self-pay|97||||97|19.4|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|TML [1980]|TML [198000]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|6.42|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97|3.97|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNICARE [2040]|UNICARE [204000]|97||||97|3.97|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97|3.97|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97|0|73.72|3.97
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97|3.97|73.72|3.97
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AARP [1000]|AARP [100000]|97||||97|4.01|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA [1015]|AETNA [101529]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMBETTER [2930]|AMBETTER [293000]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97||||97|6.58|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|69.84|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|48.5|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|48.5|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97||||97|73.72|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA [1260]|CIGNA PPO [126025]|97||||97|14.27|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97||||97|4.01|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97||||97|6.58|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|Self-pay|Self-pay|97||||97|19.4|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|TML [1980]|TML [198000]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|6.76|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97|4.01|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNICARE [2040]|UNICARE [204000]|97||||97|4.01|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97|4.01|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WEB TPA [2115]|WEB TPA [211500]|97||||97|66.93|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97|0|73.72|4.01
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WORKER'S COMP [2125]|TML WC [212537]|97||||97|4.01|73.72|4.01
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AARP [1000]|AARP [100000]|271||||271|17.51|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA [1015]|AETNA [101529]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMBETTER [2930]|AMBETTER [293000]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|271||||271|27.6|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271|195.12|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271|135.5|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271|135.5|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|271||||271|205.96|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA [1260]|CIGNA PPO [126025]|271||||271|62.23|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|271||||271|17.51|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|271||||271|27.6|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|Self-pay|Self-pay|271||||271|54.2|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|TML [1980]|TML [198000]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|28.35|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271|17.51|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNICARE [2040]|UNICARE [204000]|271||||271|17.51|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271|17.51|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WEB TPA [2115]|WEB TPA [211500]|271||||271|186.99|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271|0|205.96|17.51
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WORKER'S COMP [2125]|TML WC [212537]|271||||271|17.51|205.96|17.51
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AARP [1000]|AARP [100000]|152||||152|5.66|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA [1015]|AETNA [101529]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152||||152|8.93|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152||||152|109.44|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152||||152|76|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152||||152|76|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152||||152|115.52|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|152||||152|20.12|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152||||152|5.66|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152||||152|8.93|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|Self-pay|Self-pay|152||||152|30.4|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|TML [1980]|TML [198000]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152||||152|9.17|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152||||152|5.66|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNICARE [2040]|UNICARE [204000]|152||||152|5.66|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152||||152|5.66|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|152||||152|104.88|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|152||||152|0|115.52|5.66
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|152||||152|5.66|115.52|5.66
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AARP [1000]|AARP [100000]|359.25||||359.25|7.44|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA [1015]|AETNA [101529]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMBETTER [2930]|AMBETTER [293000]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|359.25||||359.25|11.73|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|359.25||||359.25|258.66|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|359.25||||359.25|179.63|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|359.25||||359.25|179.63|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|359.25||||359.25|273.03|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA [1260]|CIGNA PPO [126025]|359.25||||359.25|26.41|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|359.25||||359.25|7.44|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|359.25||||359.25|11.73|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|Self-pay|Self-pay|359.25||||359.25|71.85|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|TML [1980]|TML [198000]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|359.25||||359.25|12.05|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|359.25||||359.25|7.44|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNICARE [2040]|UNICARE [204000]|359.25||||359.25|7.44|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|359.25||||359.25|7.44|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WEB TPA [2115]|WEB TPA [211500]|359.25||||359.25|247.88|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|359.25||||359.25|0|273.03|7.44
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WORKER'S COMP [2125]|TML WC [212537]|359.25||||359.25|7.44|273.03|7.44
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AARP [1000]|AARP [100000]|373||||373|13.86|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA [1015]|AETNA [101529]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMBETTER [2930]|AMBETTER [293000]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|373||||373|21.84|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|373||||373|268.56|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|373||||373|186.5|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|373||||373|186.5|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|373||||373|283.48|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA [1260]|CIGNA PPO [126025]|373||||373|49.25|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|373||||373|13.86|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|373||||373|21.84|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|Self-pay|Self-pay|373||||373|74.6|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|TML [1980]|TML [198000]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|373||||373|22.43|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|373||||373|13.86|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNICARE [2040]|UNICARE [204000]|373||||373|13.86|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|373||||373|13.86|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WEB TPA [2115]|WEB TPA [211500]|373||||373|257.37|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|373||||373|0|283.48|13.86
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WORKER'S COMP [2125]|TML WC [212537]|373||||373|13.86|283.48|13.86
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AARP [1000]|AARP [100000]|8446||||8446|4.36|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AETNA [1015]|AETNA [101529]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AMBETTER [2930]|AMBETTER [293000]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8446||||8446|6.89|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8446||||8446|6081.12|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8446||||8446|4223|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8446||||8446|4223|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8446||||8446|6418.96|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA [1260]|CIGNA PPO [126025]|8446||||8446|15.52|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8446||||8446|4.36|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8446||||8446|6.89|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|Self-pay|Self-pay|8446||||8446|1689.2|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|TML [1980]|TML [198000]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8446||||8446|7.08|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8446||||8446|4.36|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UNICARE [2040]|UNICARE [204000]|8446||||8446|4.36|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8446||||8446|4.36|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WEB TPA [2115]|WEB TPA [211500]|8446||||8446|5827.74|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8446||||8446|0|6418.96|4.36
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WORKER'S COMP [2125]|TML WC [212537]|8446||||8446|4.36|6418.96|4.36
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AARP [1000]|AARP [100000]|186||||186|10.53|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA [1015]|AETNA [101529]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMBETTER [2930]|AMBETTER [293000]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|186||||186|16.59|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|133.92|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|93|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|93|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|186||||186|141.36|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA [1260]|CIGNA PPO [126025]|186||||186|37.4|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|186||||186|10.53|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|186||||186|16.59|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|Self-pay|Self-pay|186||||186|37.2|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|TML [1980]|TML [198000]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|17.04|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186|10.53|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNICARE [2040]|UNICARE [204000]|186||||186|10.53|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186|10.53|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WEB TPA [2115]|WEB TPA [211500]|186||||186|128.34|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186|0|141.36|10.53
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WORKER'S COMP [2125]|TML WC [212537]|186||||186|10.53|141.36|10.53
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AARP [1000]|AARP [100000]|229.25||||229.25|4.74|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA [1015]|AETNA [101529]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMBETTER [2930]|AMBETTER [293000]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|229.25||||229.25|7.46|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|229.25||||229.25|165.06|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|229.25||||229.25|114.63|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|229.25||||229.25|114.63|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|229.25||||229.25|174.23|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA [1260]|CIGNA PPO [126025]|229.25||||229.25|16.85|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|229.25||||229.25|4.74|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|229.25||||229.25|7.46|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|Self-pay|Self-pay|229.25||||229.25|45.85|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|TML [1980]|TML [198000]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|229.25||||229.25|7.66|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|229.25||||229.25|4.74|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNICARE [2040]|UNICARE [204000]|229.25||||229.25|4.74|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|229.25||||229.25|4.74|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WEB TPA [2115]|WEB TPA [211500]|229.25||||229.25|158.18|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|229.25||||229.25|0|174.23|4.74
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WORKER'S COMP [2125]|TML WC [212537]|229.25||||229.25|4.74|174.23|4.74
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AARP [1000]|AARP [100000]|284||||284|5.33|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA [1015]|AETNA [101529]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMBETTER [2930]|AMBETTER [293000]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|284||||284|8.41|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|284||||284|204.48|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|284||||284|142|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|284||||284|142|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|284||||284|215.84|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA [1260]|CIGNA PPO [126025]|284||||284|18.97|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|284||||284|5.33|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|284||||284|8.41|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|Self-pay|Self-pay|284||||284|56.8|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|TML [1980]|TML [198000]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|284||||284|8.63|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|284||||284|5.33|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNICARE [2040]|UNICARE [204000]|284||||284|5.33|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|284||||284|5.33|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WEB TPA [2115]|WEB TPA [211500]|284||||284|195.96|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|284||||284|0|215.84|5.33
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WORKER'S COMP [2125]|TML WC [212537]|284||||284|5.33|215.84|5.33
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AARP [1000]|AARP [100000]|621.5||||621.5|11.69|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA [1015]|AETNA [101529]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|621.5||||621.5|18.43|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|621.5||||621.5|447.48|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|621.5||||621.5|310.75|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|621.5||||621.5|310.75|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|621.5||||621.5|472.34|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|621.5||||621.5|41.54|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|621.5||||621.5|11.69|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|621.5||||621.5|18.43|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|Self-pay|Self-pay|621.5||||621.5|124.3|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|TML [1980]|TML [198000]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|621.5||||621.5|18.94|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|621.5||||621.5|11.69|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNICARE [2040]|UNICARE [204000]|621.5||||621.5|11.69|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|621.5||||621.5|11.69|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|621.5||||621.5|428.84|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|621.5||||621.5|0|472.34|11.69
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|621.5||||621.5|11.69|472.34|11.69
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AARP [1000]|AARP [100000]|675.25||||675.25|13.97|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA [1015]|AETNA [101529]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMBETTER [2930]|AMBETTER [293000]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|675.25||||675.25|22.02|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|675.25||||675.25|486.18|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|675.25||||675.25|337.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|675.25||||675.25|337.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|675.25||||675.25|513.19|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA [1260]|CIGNA PPO [126025]|675.25||||675.25|49.65|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|675.25||||675.25|13.97|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|675.25||||675.25|22.02|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|Self-pay|Self-pay|675.25||||675.25|135.05|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|TML [1980]|TML [198000]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|675.25||||675.25|22.63|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|675.25||||675.25|13.97|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNICARE [2040]|UNICARE [204000]|675.25||||675.25|13.97|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|675.25||||675.25|13.97|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WEB TPA [2115]|WEB TPA [211500]|675.25||||675.25|465.92|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|675.25||||675.25|0|513.19|13.97
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WORKER'S COMP [2125]|TML WC [212537]|675.25||||675.25|13.97|513.19|13.97
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AARP [1000]|AARP [100000]|199||||199|8.12|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA [1015]|AETNA [101529]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMBETTER [2930]|AMBETTER [293000]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|199||||199|16.21|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|199||||199|143.28|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|199||||199|99.5|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|199||||199|99.5|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|199||||199|151.24|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA [1260]|CIGNA PPO [126025]|199||||199|28.83|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|199||||199|8.12|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|199||||199|16.21|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|Self-pay|Self-pay|199||||199|39.8|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|TML [1980]|TML [198000]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|199||||199|16.65|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|199||||199|8.12|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNICARE [2040]|UNICARE [204000]|199||||199|8.12|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|199||||199|8.12|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WEB TPA [2115]|WEB TPA [211500]|199||||199|137.31|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|199||||199|0|151.24|8.12
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WORKER'S COMP [2125]|TML WC [212537]|199||||199|8.12|151.24|8.12
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AARP [1000]|AARP [100000]|1249||||1249|3.26|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA [1015]|AETNA [101529]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMBETTER [2930]|AMBETTER [293000]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1249||||1249|5.14|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1249||||1249|899.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1249||||1249|624.5|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1249||||1249|624.5|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1249||||1249|949.24|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA [1260]|CIGNA PPO [126025]|1249||||1249|11.59|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1249||||1249|3.26|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1249||||1249|5.14|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|Self-pay|Self-pay|1249||||1249|249.8|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|TML [1980]|TML [198000]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1249||||1249|5.28|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1249||||1249|3.26|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNICARE [2040]|UNICARE [204000]|1249||||1249|3.26|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1249||||1249|3.26|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WEB TPA [2115]|WEB TPA [211500]|1249||||1249|861.81|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1249||||1249|0|949.24|3.26
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WORKER'S COMP [2125]|TML WC [212537]|1249||||1249|3.26|949.24|3.26
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AARP [1000]|AARP [100000]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA [1015]|AETNA [101529]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMBETTER [2930]|AMBETTER [293000]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|80||||80|7.23|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80||||80|57.6|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80||||80|40|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80||||80|40|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|80||||80|60.8|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA [1260]|CIGNA PPO [126025]|80||||80|13.94|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|80||||80|7.23|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|Self-pay|Self-pay|80||||80|16|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|TML [1980]|TML [198000]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNICARE [2040]|UNICARE [204000]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80||||80||60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WEB TPA [2115]|WEB TPA [211500]|80||||80|55.2|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80||||80|0|60.8|7.23
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WORKER'S COMP [2125]|TML WC [212537]|80||||80||60.8|7.23
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AARP [1000]|AARP [100000]|189.25||||189.25|3.73|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|5.88|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|136.26|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|94.63|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|94.63|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|143.83|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.24|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25|3.73|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|5.88|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|Self-pay|Self-pay|189.25||||189.25|37.85|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25|6.04|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25|3.73|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25|3.73|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25|3.73|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.25||||189.25|0|143.83|3.73
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25|3.73|143.83|3.73
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AARP [1000]|AARP [100000]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|6.6|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|136.26|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|94.63|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|94.63|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|143.83|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.94|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|6.6|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|Self-pay|Self-pay|189.25||||189.25|37.85|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25||143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.25||||189.25|0|143.83|6.6
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25||143.83|6.6
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AARP [1000]|AARP [100000]|462||||462|9.57|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA [1015]|AETNA [101529]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMBETTER [2930]|AMBETTER [293000]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|462||||462|15.09|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|462||||462|332.64|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|462||||462|231|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|462||||462|231|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|462||||462|351.12|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA [1260]|CIGNA PPO [126025]|462||||462|34.03|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|462||||462|9.57|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|462||||462|15.09|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|Self-pay|Self-pay|462||||462|92.4|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|TML [1980]|TML [198000]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|462||||462|15.5|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|462||||462|9.57|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNICARE [2040]|UNICARE [204000]|462||||462|9.57|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|462||||462|9.57|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WEB TPA [2115]|WEB TPA [211500]|462||||462|318.78|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|462||||462|0|351.12|9.57
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WORKER'S COMP [2125]|TML WC [212537]|462||||462|9.57|351.12|9.57
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AARP [1000]|AARP [100000]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA [1015]|AETNA [101529]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMBETTER [2930]|AMBETTER [293000]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|261||||261|17.84|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261||||261|187.92|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261||||261|130.5|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261||||261|130.5|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|261||||261|198.36|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA [1260]|CIGNA PPO [126025]|261||||261|40.22|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|GROUP PENSION ADMIN [1450]|GPA [145000]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|261||||261|17.84|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|PHCS [1780]|PHCS MULTIPLAN [178000]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|Self-pay|Self-pay|261||||261|52.2|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|TML [1980]|TML [198000]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNICARE [2040]|UNICARE [204000]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261||||261||198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WEB TPA [2115]|WEB TPA [211500]|261||||261|180.09|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261||||261|0|198.36|17.84
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WORKER'S COMP [2125]|TML WC [212537]|261||||261||198.36|17.84
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AARP [1000]|AARP [100000]|152||||152|6.2|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA [1015]|AETNA [101529]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMBETTER [2930]|AMBETTER [293000]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152||||152|9.78|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152||||152|109.44|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152||||152|76|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152||||152|76|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152||||152|115.52|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA [1260]|CIGNA PPO [126025]|152||||152|22.04|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152||||152|6.2|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152||||152|9.78|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|Self-pay|Self-pay|152||||152|30.4|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|TML [1980]|TML [198000]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152||||152|10.05|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152||||152|6.2|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNICARE [2040]|UNICARE [204000]|152||||152|6.2|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152||||152|6.2|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WEB TPA [2115]|WEB TPA [211500]|152||||152|104.88|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|152||||152|0|115.52|6.2
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WORKER'S COMP [2125]|TML WC [212537]|152||||152|6.2|115.52|6.2
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AARP [1000]|AARP [100000]|647||||647||491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA [1015]|AETNA [101529]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMBETTER [2930]|AMBETTER [293000]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|647||||647|323.5|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|647||||647|465.84|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|647||||647|323.5|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|647||||647|323.5|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|647||||647|491.72|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA [1260]|CIGNA PPO [126025]|647||||647|42.04|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|647||||647||491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|647||||647|323.5|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|Self-pay|Self-pay|647||||647|129.4|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|TML [1980]|TML [198000]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|647||||647|251.81|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|647||||647||491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNICARE [2040]|UNICARE [204000]|647||||647||491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|647||||647||491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WEB TPA [2115]|WEB TPA [211500]|647||||647|446.43|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|647||||647|0|491.72|42.04
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WORKER'S COMP [2125]|TML WC [212537]|647||||647||491.72|42.04
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AARP [1000]|AARP [100000]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA [1015]|AETNA [101529]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMBETTER [2930]|AMBETTER [293000]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|390||||390|23.88|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|390||||390|280.8|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|390||||390|195|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|390||||390|195|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|390||||390|296.4|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA [1260]|CIGNA PPO [126025]|390||||390|53.82|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|390||||390|23.88|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|Self-pay|Self-pay|390||||390|78|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|TML [1980]|TML [198000]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNICARE [2040]|UNICARE [204000]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|390||||390||296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WEB TPA [2115]|WEB TPA [211500]|390||||390|269.1|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|390||||390|0|296.4|23.88
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WORKER'S COMP [2125]|TML WC [212537]|390||||390||296.4|23.88
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AARP [1000]|AARP [100000]|481.75||||481.75|9.97|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA [1015]|AETNA [101529]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMBETTER [2930]|AMBETTER [293000]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|481.75||||481.75|15.72|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|481.75||||481.75|346.86|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|481.75||||481.75|240.88|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|481.75||||481.75|240.88|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|481.75||||481.75|366.13|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA [1260]|CIGNA PPO [126025]|481.75||||481.75|35.45|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|481.75||||481.75|9.97|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|481.75||||481.75|15.72|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|Self-pay|Self-pay|481.75||||481.75|96.35|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|TML [1980]|TML [198000]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|481.75||||481.75|16.15|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|481.75||||481.75|9.97|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNICARE [2040]|UNICARE [204000]|481.75||||481.75|9.97|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|481.75||||481.75|9.97|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WEB TPA [2115]|WEB TPA [211500]|481.75||||481.75|332.41|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|481.75||||481.75|0|366.13|9.97
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WORKER'S COMP [2125]|TML WC [212537]|481.75||||481.75|9.97|366.13|9.97
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AARP [1000]|AARP [100000]|279.45||||279.45|3.9|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA [1015]|AETNA [101529]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMBETTER [2930]|AMBETTER [293000]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|279.45||||279.45|6.14|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|279.45||||279.45|201.2|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|279.45||||279.45|139.73|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|279.45||||279.45|139.73|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|279.45||||279.45|212.38|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA [1260]|CIGNA PPO [126025]|279.45||||279.45|13.87|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|279.45||||279.45|3.9|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|279.45||||279.45|6.14|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|Self-pay|Self-pay|279.45||||279.45|55.89|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|TML [1980]|TML [198000]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|279.45||||279.45|108.76|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|279.45||||279.45|3.9|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNICARE [2040]|UNICARE [204000]|279.45||||279.45|3.9|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|279.45||||279.45|3.9|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WEB TPA [2115]|WEB TPA [211500]|279.45||||279.45|192.82|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|279.45||||279.45|0|212.38|3.9
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WORKER'S COMP [2125]|TML WC [212537]|279.45||||279.45|3.9|212.38|3.9
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AARP [1000]|AARP [100000]|243||||243|4.54|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA [1015]|AETNA [101529]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMBETTER [2930]|AMBETTER [293000]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|243||||243|7.28|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|243||||243|174.96|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|243||||243|121.5|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|243||||243|121.5|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|243||||243|184.68|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|243||||243|16.15|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|243||||243|4.54|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|243||||243|7.28|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|Self-pay|Self-pay|243||||243|48.6|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|TML [1980]|TML [198000]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|243||||243|94.58|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|243||||243|4.54|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNICARE [2040]|UNICARE [204000]|243||||243|4.54|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|243||||243|4.54|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WEB TPA [2115]|WEB TPA [211500]|243||||243|167.67|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|243||||243|0|184.68|4.54
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]|243||||243|0|184.68|4.54
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|243||||243|4.54|184.68|4.54
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AARP [1000]|AARP [100000]|136.62||||136.62|3.52|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA [1015]|AETNA [101529]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMBETTER [2930]|AMBETTER [293000]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|136.62||||136.62|5.55|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.62||||136.62|98.37|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.62||||136.62|68.31|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.62||||136.62|68.31|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|136.62||||136.62|103.83|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA [1260]|CIGNA PPO [126025]|136.62||||136.62|12.51|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|136.62||||136.62|3.52|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|136.62||||136.62|5.55|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|Self-pay|Self-pay|136.62||||136.62|27.32|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|TML [1980]|TML [198000]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.62||||136.62|53.17|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.62||||136.62|3.52|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNICARE [2040]|UNICARE [204000]|136.62||||136.62|3.52|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.62||||136.62|3.52|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WEB TPA [2115]|WEB TPA [211500]|136.62||||136.62|94.27|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.62||||136.62|0|103.83|3.52
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WORKER'S COMP [2125]|TML WC [212537]|136.62||||136.62|3.52|103.83|3.52
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AARP [1000]|AARP [100000]|367||||367|5.9|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA [1015]|AETNA [101529]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMBETTER [2930]|AMBETTER [293000]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|367||||367|9.53|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|367||||367|264.24|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|367||||367|183.5|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|367||||367|183.5|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|367||||367|278.92|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA [1260]|CIGNA PPO [126025]|367||||367|20.99|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|367||||367|5.9|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|367||||367|9.53|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|Self-pay|Self-pay|367||||367|73.4|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|TML [1980]|TML [198000]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|367||||367|142.84|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|367||||367|5.9|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNICARE [2040]|UNICARE [204000]|367||||367|5.9|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|367||||367|5.9|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WEB TPA [2115]|WEB TPA [211500]|367||||367|253.23|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|367||||367|0|278.92|5.9
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WORKER'S COMP [2125]|TML WC [212537]|367||||367|5.9|278.92|5.9
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AARP [1000]|AARP [100000]|299.46||||299.46||227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA [1015]|AETNA [101529]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMBETTER [2930]|AMBETTER [293000]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|299.46||||299.46|7.53|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299.46||||299.46|215.61|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299.46||||299.46|149.73|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299.46||||299.46|149.73|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|299.46||||299.46|227.59|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA [1260]|CIGNA PPO [126025]|299.46||||299.46|13.94|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|299.46||||299.46||227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|299.46||||299.46|7.53|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|Self-pay|Self-pay|299.46||||299.46|59.89|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|TML [1980]|TML [198000]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299.46||||299.46|116.55|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299.46||||299.46||227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNICARE [2040]|UNICARE [204000]|299.46||||299.46||227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299.46||||299.46||227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WEB TPA [2115]|WEB TPA [211500]|299.46||||299.46|206.63|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299.46||||299.46|0|227.59|7.53
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WORKER'S COMP [2125]|TML WC [212537]|299.46||||299.46||227.59|7.53
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AARP [1000]|AARP [100000]|432||||432||328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AETNA [1015]|AETNA [101529]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AMBETTER [2930]|AMBETTER [293000]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|432||||432|193.91|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432|311.04|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432|216|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432|216|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|432||||432|328.32|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA [1260]|CIGNA PPO [126025]|432||||432|35.45|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|432||||432||328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|432||||432|193.91|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|Self-pay|Self-pay|432||||432|86.4|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|TML [1980]|TML [198000]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|168.13|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432||328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UNICARE [2040]|UNICARE [204000]|432||||432||328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432||328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|WEB TPA [2115]|WEB TPA [211500]|432||||432|298.08|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432|0|328.32|35.45
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|0|328.32|35.45
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|WORKER'S COMP [2125]|TML WC [212537]|432||||432||328.32|35.45
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AARP [1000]|AARP [100000]|144||||144|6.02|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AETNA [1015]|AETNA [101529]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AMBETTER [2930]|AMBETTER [293000]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|144||||144|9.49|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|103.68|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|72|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|72|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|144||||144|109.44|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA [1260]|CIGNA PPO [126025]|144||||144|21.42|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|144||||144|6.02|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|144||||144|9.49|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|Self-pay|Self-pay|144||||144|28.8|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|TML [1980]|TML [198000]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|9.75|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|6.02|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UNICARE [2040]|UNICARE [204000]|144||||144|6.02|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|6.02|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WEB TPA [2115]|WEB TPA [211500]|144||||144|99.36|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|0|109.44|6.02
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WORKER'S COMP [2125]|TML WC [212537]|144||||144|6.02|109.44|6.02
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AARP [1000]|AARP [100000]|102||||102|4.27|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA [1015]|AETNA [101529]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMBETTER [2930]|AMBETTER [293000]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|102||||102|6.73|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|73.44|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|51|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|51|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|102||||102|77.52|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA [1260]|CIGNA PPO [126025]|102||||102|15.16|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|102||||102|4.27|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|102||||102|6.73|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|Self-pay|Self-pay|102||||102|20.4|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|TML [1980]|TML [198000]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|6.92|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102|4.27|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNICARE [2040]|UNICARE [204000]|102||||102|4.27|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102|4.27|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WEB TPA [2115]|WEB TPA [211500]|102||||102|70.38|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102|0|77.52|4.27
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WORKER'S COMP [2125]|TML WC [212537]|102||||102|4.27|77.52|4.27
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AARP [1000]|AARP [100000]|506||||506|10.68|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA [1015]|AETNA [101529]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMBETTER [2930]|AMBETTER [293000]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|506||||506|16.84|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|506||||506|364.32|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|506||||506|253|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|506||||506|253|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|506||||506|384.56|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA [1260]|CIGNA PPO [126025]|506||||506|37.93|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|506||||506|10.68|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|506||||506|16.84|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|Self-pay|Self-pay|506||||506|101.2|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|TML [1980]|TML [198000]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|506||||506|17.3|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|506||||506|10.68|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNICARE [2040]|UNICARE [204000]|506||||506|10.68|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|506||||506|10.68|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WEB TPA [2115]|WEB TPA [211500]|506||||506|349.14|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|506||||506|0|384.56|10.68
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WORKER'S COMP [2125]|TML WC [212537]|506||||506|10.68|384.56|10.68
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AARP [1000]|AARP [100000]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AETNA [1015]|AETNA [101529]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AMBETTER [2930]|AMBETTER [293000]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|301.5||||301.5|33.09|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|301.5||||301.5|217.08|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|301.5||||301.5|150.75|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|301.5||||301.5|150.75|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|301.5||||301.5|229.14|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA [1260]|CIGNA PPO [126025]|301.5||||301.5|74.57|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|301.5||||301.5|33.09|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|Self-pay|Self-pay|301.5||||301.5|60.3|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|TML [1980]|TML [198000]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UNICARE [2040]|UNICARE [204000]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|301.5||||301.5||229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WEB TPA [2115]|WEB TPA [211500]|301.5||||301.5|208.04|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|301.5||||301.5|0|229.14|33.09
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WORKER'S COMP [2125]|TML WC [212537]|301.5||||301.5||229.14|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AARP [1000]|AARP [100000]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA [1015]|AETNA [101529]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMBETTER [2930]|AMBETTER [293000]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|313||||313|33.09|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|313||||313|225.36|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|313||||313|156.5|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|313||||313|156.5|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|313||||313|237.88|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA [1260]|CIGNA PPO [126025]|313||||313|74.57|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|313||||313|33.09|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|Self-pay|Self-pay|313||||313|62.6|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|TML [1980]|TML [198000]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNICARE [2040]|UNICARE [204000]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|313||||313||237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WEB TPA [2115]|WEB TPA [211500]|313||||313|215.97|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|313||||313|0|237.88|33.09
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WORKER'S COMP [2125]|TML WC [212537]|313||||313||237.88|33.09
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AARP [1000]|AARP [100000]|478.5||||478.5|9.9|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AETNA [1015]|AETNA [101529]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AMBETTER [2930]|AMBETTER [293000]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.5||||478.5|15.6|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.5||||478.5|344.52|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.5||||478.5|239.25|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.5||||478.5|239.25|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.5||||478.5|363.66|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA [1260]|CIGNA PPO [126025]|478.5||||478.5|35.19|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.5||||478.5|9.9|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.5||||478.5|15.6|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|Self-pay|Self-pay|478.5||||478.5|95.7|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|TML [1980]|TML [198000]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.5||||478.5|16.03|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.5||||478.5|9.9|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UNICARE [2040]|UNICARE [204000]|478.5||||478.5|9.9|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.5||||478.5|9.9|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WEB TPA [2115]|WEB TPA [211500]|478.5||||478.5|330.17|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.5||||478.5|0|363.66|9.9
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WORKER'S COMP [2125]|TML WC [212537]|478.5||||478.5|9.9|363.66|9.9
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AARP [1000]|AARP [100000]|480.5||||480.5|11.33|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AETNA [1015]|AETNA [101529]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AMBETTER [2930]|AMBETTER [293000]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|480.5||||480.5|17.86|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|480.5||||480.5|345.96|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|480.5||||480.5|240.25|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|480.5||||480.5|240.25|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|480.5||||480.5|365.18|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA [1260]|CIGNA PPO [126025]|480.5||||480.5|40.25|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|480.5||||480.5|11.33|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|480.5||||480.5|17.86|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|Self-pay|Self-pay|480.5||||480.5|96.1|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|TML [1980]|TML [198000]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|480.5||||480.5|18.35|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|480.5||||480.5|11.33|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UNICARE [2040]|UNICARE [204000]|480.5||||480.5|11.33|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|480.5||||480.5|11.33|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WEB TPA [2115]|WEB TPA [211500]|480.5||||480.5|331.55|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|480.5||||480.5|0|365.18|11.33
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WORKER'S COMP [2125]|TML WC [212537]|480.5||||480.5|11.33|365.18|11.33
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AARP [1000]|AARP [100000]|854.25||||854.25|14.79|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AETNA [1015]|AETNA [101529]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AMBETTER [2930]|AMBETTER [293000]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|854.25||||854.25|23.31|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|854.25||||854.25|615.06|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|854.25||||854.25|427.13|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|854.25||||854.25|427.13|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|854.25||||854.25|649.23|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA [1260]|CIGNA PPO [126025]|854.25||||854.25|52.56|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|854.25||||854.25|14.79|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|854.25||||854.25|23.31|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|Self-pay|Self-pay|854.25||||854.25|170.85|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|TML [1980]|TML [198000]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|854.25||||854.25|23.95|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|854.25||||854.25|14.79|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UNICARE [2040]|UNICARE [204000]|854.25||||854.25|14.79|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|854.25||||854.25|14.79|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WEB TPA [2115]|WEB TPA [211500]|854.25||||854.25|589.43|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|854.25||||854.25|0|649.23|14.79
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WORKER'S COMP [2125]|TML WC [212537]|854.25||||854.25|14.79|649.23|14.79
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AARP [1000]|AARP [100000]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA [1015]|AETNA [101529]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|480.5||||480.5|15.67|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|480.5||||480.5|345.96|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|480.5||||480.5|240.25|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|480.5||||480.5|240.25|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|480.5||||480.5|365.18|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|480.5||||480.5|35.32|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|480.5||||480.5|15.67|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|Self-pay|Self-pay|480.5||||480.5|96.1|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|TML [1980]|TML [198000]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNICARE [2040]|UNICARE [204000]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|480.5||||480.5||365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|480.5||||480.5|331.55|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|480.5||||480.5|0|365.18|15.67
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|480.5||||480.5||365.18|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AARP [1000]|AARP [100000]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA [1015]|AETNA [101529]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMBETTER [2930]|AMBETTER [293000]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|462.5||||462.5|15.67|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|462.5||||462.5|333|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|462.5||||462.5|231.25|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|462.5||||462.5|231.25|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|462.5||||462.5|351.5|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA [1260]|CIGNA PPO [126025]|462.5||||462.5|35.32|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|462.5||||462.5|15.67|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|Self-pay|Self-pay|462.5||||462.5|92.5|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|TML [1980]|TML [198000]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNICARE [2040]|UNICARE [204000]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|462.5||||462.5||351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WEB TPA [2115]|WEB TPA [211500]|462.5||||462.5|319.13|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|462.5||||462.5|0|351.5|15.67
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WORKER'S COMP [2125]|TML WC [212537]|462.5||||462.5||351.5|15.67
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AARP [1000]|AARP [100000]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AETNA [1015]|AETNA [101529]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AMBETTER [2930]|AMBETTER [293000]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326.25||||326.25|10.65|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326.25||||326.25|234.9|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326.25||||326.25|163.13|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326.25||||326.25|163.13|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326.25||||326.25|247.95|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|CIGNA [1260]|CIGNA PPO [126025]|326.25||||326.25|24|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326.25||||326.25|10.65|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|Self-pay|Self-pay|326.25||||326.25|65.25|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|TML [1980]|TML [198000]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|UNICARE [2040]|UNICARE [204000]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326.25||||326.25||247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|WEB TPA [2115]|WEB TPA [211500]|326.25||||326.25|225.11|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326.25||||326.25|0|247.95|10.65
30286280|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMAGGLUTINATION INHIBITION TEST HAI|1|WORKER'S COMP [2125]|TML WC [212537]|326.25||||326.25||247.95|10.65
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AARP [1000]|AARP [100000]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AETNA [1015]|AETNA [101529]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AMBETTER [2930]|AMBETTER [293000]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|188||||188|18.27|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|135.36|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|94|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|94|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|188||||188|142.88|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|CIGNA [1260]|CIGNA PPO [126025]|188||||188|41.14|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|188||||188|18.27|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|Self-pay|Self-pay|188||||188|37.6|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|TML [1980]|TML [198000]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|UNICARE [2040]|UNICARE [204000]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188||142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|WEB TPA [2115]|WEB TPA [211500]|188||||188|129.72|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188|0|142.88|18.27
30286329|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION|1|WORKER'S COMP [2125]|TML WC [212537]|188||||188||142.88|18.27
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AARP [1000]|AARP [100000]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AETNA [1015]|AETNA [101529]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AMBETTER [2930]|AMBETTER [293000]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|243||||243|38.16|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|243||||243|174.96|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|243||||243|121.5|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|243||||243|121.5|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|243||||243|184.68|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA [1260]|CIGNA PPO [126025]|243||||243|85.99|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|243||||243|38.16|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|Self-pay|Self-pay|243||||243|48.6|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|TML [1980]|TML [198000]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UNICARE [2040]|UNICARE [204000]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|243||||243||184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WEB TPA [2115]|WEB TPA [211500]|243||||243|167.67|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|243||||243|0|184.68|38.16
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WORKER'S COMP [2125]|TML WC [212537]|243||||243||184.68|38.16
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AARP [1000]|AARP [100000]|664.5||||664.5|16.32|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA [1015]|AETNA [101529]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMBETTER [2930]|AMBETTER [293000]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|664.5||||664.5|30.64|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|664.5||||664.5|478.44|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|664.5||||664.5|332.25|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|664.5||||664.5|332.25|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|664.5||||664.5|505.02|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA [1260]|CIGNA PPO [126025]|664.5||||664.5|57.99|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|664.5||||664.5|16.32|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|664.5||||664.5|30.64|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|Self-pay|Self-pay|664.5||||664.5|132.9|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|TML [1980]|TML [198000]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|664.5||||664.5|31.48|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|664.5||||664.5|16.32|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNICARE [2040]|UNICARE [204000]|664.5||||664.5|16.32|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|664.5||||664.5|16.32|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WEB TPA [2115]|WEB TPA [211500]|664.5||||664.5|458.51|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|664.5||||664.5|0|505.02|16.32
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WORKER'S COMP [2125]|TML WC [212537]|664.5||||664.5|16.32|505.02|16.32
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AARP [1000]|AARP [100000]|579.75||||579.75|11.99|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AETNA [1015]|AETNA [101529]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AMBETTER [2930]|AMBETTER [293000]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|579.75||||579.75|18.92|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|579.75||||579.75|417.42|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|579.75||||579.75|289.88|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|579.75||||579.75|289.88|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|579.75||||579.75|440.61|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA [1260]|CIGNA PPO [126025]|579.75||||579.75|42.63|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|579.75||||579.75|11.99|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|579.75||||579.75|18.92|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|Self-pay|Self-pay|579.75||||579.75|115.95|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|TML [1980]|TML [198000]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|579.75||||579.75|19.43|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|579.75||||579.75|11.99|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UNICARE [2040]|UNICARE [204000]|579.75||||579.75|11.99|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|579.75||||579.75|11.99|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WEB TPA [2115]|WEB TPA [211500]|579.75||||579.75|400.03|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|579.75||||579.75|0|440.61|11.99
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WORKER'S COMP [2125]|TML WC [212537]|579.75||||579.75|11.99|440.61|11.99
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AARP [1000]|AARP [100000]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|15|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|344.34|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|239.13|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|239.13|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|363.47|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|29.86|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|15|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|Self-pay|Self-pay|478.25||||478.25|95.65|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25||363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25|0|363.47|15
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25||363.47|15
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AARP [1000]|AARP [100000]|111||||111|4.68|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AETNA [1015]|AETNA [101529]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMBETTER [2930]|AMBETTER [293000]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|111||||111|7.98|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111||||111|79.92|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111||||111|55.5|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111||||111|55.5|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|111||||111|84.36|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|CIGNA [1260]|CIGNA PPO [126025]|111||||111|16.62|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|111||||111|4.68|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|111||||111|7.98|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|Self-pay|Self-pay|111||||111|22.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|TML [1980]|TML [198000]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111||||111|8.2|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111||||111|4.68|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UNICARE [2040]|UNICARE [204000]|111||||111|4.68|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111||||111|4.68|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WEB TPA [2115]|WEB TPA [211500]|111||||111|76.59|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111||||111|0|84.36|4.68
30286430|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QL|1|WORKER'S COMP [2125]|TML WC [212537]|111||||111|4.68|84.36|4.68
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AARP [1000]|AARP [100000]|1475.25||||1475.25|51.12|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AETNA [1015]|AETNA [101529]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AMBETTER [2930]|AMBETTER [293000]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1475.25||||1475.25|80.57|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1475.25||||1475.25|1062.18|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1475.25||||1475.25|737.63|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1475.25||||1475.25|737.63|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1475.25||||1475.25|1121.19|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA [1260]|CIGNA PPO [126025]|1475.25||||1475.25|181.65|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1475.25||||1475.25|51.12|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1475.25||||1475.25|80.57|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|Self-pay|Self-pay|1475.25||||1475.25|295.05|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|TML [1980]|TML [198000]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1475.25||||1475.25|82.78|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1475.25||||1475.25|51.12|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UNICARE [2040]|UNICARE [204000]|1475.25||||1475.25|51.12|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1475.25||||1475.25|51.12|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WEB TPA [2115]|WEB TPA [211500]|1475.25||||1475.25|1017.92|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1475.25||||1475.25|0|1121.19|51.12
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WORKER'S COMP [2125]|TML WC [212537]|1475.25||||1475.25|51.12|1121.19|51.12
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AARP [1000]|AARP [100000]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AETNA [1015]|AETNA [101529]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AMBETTER [2930]|AMBETTER [293000]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|141||||141|130|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|141||||141||141|28.2
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]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141||||141|101.52|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141||||141|70.5|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141||||141|70.5|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|141||||141|107.16|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|141||||141|97.29|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA [1260]|CIGNA PPO [126025]|141||||141|141|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|141||||141|97.29|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|141||||141|130|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|141||||141|97.29|141|28.2
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]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141||||141|0|141|28.2
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]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|141||||141|97.29|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|Self-pay|Self-pay|141||||141|28.2|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|TML [1980]|TML [198000]|141||||141|97.29|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UNICARE [2040]|UNICARE [204000]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141||||141||141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|WEB TPA [2115]|WEB TPA [211500]|141||||141|97.29|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141||||141|0|141|28.2
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]|141||||141|0|141|28.2
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|WORKER'S COMP [2125]|TML WC [212537]|141||||141||141|28.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AARP [1000]|AARP [100000]|16||||16||32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA [1015]|AETNA [101529]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMBETTER [2930]|AMBETTER [293000]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16||||16|32.07|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16||||16|11.52|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16||||16|8|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16||||16|8|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16||||16|12.16|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA [1260]|CIGNA PPO [126025]|16||||16|16|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16||||16||32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16||||16|32.07|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|Self-pay|Self-pay|16||||16|3.2|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|TML [1980]|TML [198000]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16||||16|6.23|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16||||16||32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNICARE [2040]|UNICARE [204000]|16||||16||32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16||||16||32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WEB TPA [2115]|WEB TPA [211500]|16||||16|11.04|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16||||16|0|32.07|3.2
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WORKER'S COMP [2125]|TML WC [212537]|16||||16||32.07|3.2
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AARP [1000]|AARP [100000]|84||||84|3.52|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA [1015]|AETNA [101529]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMBETTER [2930]|AMBETTER [293000]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|84||||84|5.55|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84||||84|60.48|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84||||84|42|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84||||84|42|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|84||||84|63.84|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA [1260]|CIGNA PPO [126025]|84||||84|12.51|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|84||||84|3.52|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|84||||84|5.55|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|Self-pay|Self-pay|84||||84|16.8|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|TML [1980]|TML [198000]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84||||84|5.71|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84||||84|3.52|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNICARE [2040]|UNICARE [204000]|84||||84|3.52|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84||||84|3.52|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WEB TPA [2115]|WEB TPA [211500]|84||||84|57.96|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84||||84|0|63.84|3.52
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WORKER'S COMP [2125]|TML WC [212537]|84||||84|3.52|63.84|3.52
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AARP [1000]|AARP [100000]|326||||326|8.39|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA [1015]|AETNA [101529]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|13.23|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|234.72|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|163|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|247.76|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|29.86|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326|8.39|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|13.23|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|Self-pay|Self-pay|326||||326|65.2|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|TML [1980]|TML [198000]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326|13.59|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326|8.39|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNICARE [2040]|UNICARE [204000]|326||||326|8.39|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326|8.39|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|0|247.76|8.39
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326|8.39|247.76|8.39
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AARP [1000]|AARP [100000]|678.75||||678.75|14.05|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA [1015]|AETNA [101529]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMBETTER [2930]|AMBETTER [293000]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|678.75||||678.75|22.14|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|678.75||||678.75|488.7|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|678.75||||678.75|339.38|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|678.75||||678.75|339.38|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|678.75||||678.75|515.85|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA [1260]|CIGNA PPO [126025]|678.75||||678.75|49.91|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|678.75||||678.75|14.05|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|678.75||||678.75|22.14|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|Self-pay|Self-pay|678.75||||678.75|135.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|TML [1980]|TML [198000]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|678.75||||678.75|22.75|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|678.75||||678.75|14.05|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNICARE [2040]|UNICARE [204000]|678.75||||678.75|14.05|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|678.75||||678.75|14.05|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WEB TPA [2115]|WEB TPA [211500]|678.75||||678.75|468.34|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|678.75||||678.75|0|515.85|14.05
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WORKER'S COMP [2125]|TML WC [212537]|678.75||||678.75|14.05|515.85|14.05
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AARP [1000]|AARP [100000]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA [1015]|AETNA [101529]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|14.91|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|234.72|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|163|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|247.76|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|33.63|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|14.91|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|Self-pay|Self-pay|326||||326|65.2|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|TML [1980]|TML [198000]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNICARE [2040]|UNICARE [204000]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|0|247.76|14.91
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||247.76|14.91
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AARP [1000]|AARP [100000]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA [1015]|AETNA [101529]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMBETTER [2930]|AMBETTER [293000]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|823||||823|15.76|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|823||||823|592.56|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|823||||823|411.5|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|823||||823|411.5|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|823||||823|625.48|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA [1260]|CIGNA PPO [126025]|823||||823|35.52|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|823||||823|15.76|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|Self-pay|Self-pay|823||||823|164.6|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|TML [1980]|TML [198000]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNICARE [2040]|UNICARE [204000]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|823||||823||625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WEB TPA [2115]|WEB TPA [211500]|823||||823|567.87|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|823||||823|0|625.48|15.76
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WORKER'S COMP [2125]|TML WC [212537]|823||||823||625.48|15.76
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AARP [1000]|AARP [100000]|573.5||||573.5|11.87|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AETNA [1015]|AETNA [101529]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AMBETTER [2930]|AMBETTER [293000]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|573.5||||573.5|18.71|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|573.5||||573.5|412.92|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|573.5||||573.5|286.75|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|573.5||||573.5|286.75|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|573.5||||573.5|435.86|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA [1260]|CIGNA PPO [126025]|573.5||||573.5|42.2|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|573.5||||573.5|11.87|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|573.5||||573.5|18.71|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|Self-pay|Self-pay|573.5||||573.5|114.7|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|TML [1980]|TML [198000]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|573.5||||573.5|19.22|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|573.5||||573.5|11.87|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UNICARE [2040]|UNICARE [204000]|573.5||||573.5|11.87|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|573.5||||573.5|11.87|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WEB TPA [2115]|WEB TPA [211500]|573.5||||573.5|395.72|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|573.5||||573.5|0|435.86|11.87
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WORKER'S COMP [2125]|TML WC [212537]|573.5||||573.5|11.87|435.86|11.87
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AARP [1000]|AARP [100000]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AETNA [1015]|AETNA [101529]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AMBETTER [2930]|AMBETTER [293000]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51||||51|21.91|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51||||51|36.72|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51||||51|25.5|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51||||51|25.5|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51||||51|38.76|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA [1260]|CIGNA PPO [126025]|51||||51|49.39|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51||||51|21.91|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|Self-pay|Self-pay|51||||51|10.2|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|TML [1980]|TML [198000]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UNICARE [2040]|UNICARE [204000]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51||||51||49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WEB TPA [2115]|WEB TPA [211500]|51||||51|35.19|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51||||51|0|49.39|10.2
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WORKER'S COMP [2125]|TML WC [212537]|51||||51||49.39|10.2
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AARP [1000]|AARP [100000]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AETNA [1015]|AETNA [101529]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|16.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|234.72|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|163|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|247.76|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|38.2|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|16.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|Self-pay|Self-pay|326||||326|65.2|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|TML [1980]|TML [198000]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UNICARE [2040]|UNICARE [204000]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|0|247.76|16.94
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||247.76|16.94
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AARP [1000]|AARP [100000]|609.5||||609.5|12.62|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AETNA [1015]|AETNA [101529]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AMBETTER [2930]|AMBETTER [293000]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.5||||609.5|19.88|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.5||||609.5|438.84|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.5||||609.5|304.75|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.5||||609.5|304.75|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|609.5||||609.5|463.22|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA [1260]|CIGNA PPO [126025]|609.5||||609.5|44.85|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.5||||609.5|12.62|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.5||||609.5|19.88|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|Self-pay|Self-pay|609.5||||609.5|121.9|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|TML [1980]|TML [198000]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.5||||609.5|20.42|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.5||||609.5|12.62|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UNICARE [2040]|UNICARE [204000]|609.5||||609.5|12.62|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.5||||609.5|12.62|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WEB TPA [2115]|WEB TPA [211500]|609.5||||609.5|420.56|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.5||||609.5|0|463.22|12.62
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WORKER'S COMP [2125]|TML WC [212537]|609.5||||609.5|12.62|463.22|12.62
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AARP [1000]|AARP [100000]|772.75||||772.75|14.96|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AETNA [1015]|AETNA [101529]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AMBETTER [2930]|AMBETTER [293000]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|772.75||||772.75|23.58|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|772.75||||772.75|556.38|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|772.75||||772.75|386.38|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|772.75||||772.75|386.38|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|772.75||||772.75|587.29|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA [1260]|CIGNA PPO [126025]|772.75||||772.75|53.19|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|772.75||||772.75|14.96|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|772.75||||772.75|23.58|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|Self-pay|Self-pay|772.75||||772.75|154.55|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|TML [1980]|TML [198000]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|772.75||||772.75|24.23|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|772.75||||772.75|14.96|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UNICARE [2040]|UNICARE [204000]|772.75||||772.75|14.96|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|772.75||||772.75|14.96|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WEB TPA [2115]|WEB TPA [211500]|772.75||||772.75|533.2|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|772.75||||772.75|0|587.29|14.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WORKER'S COMP [2125]|TML WC [212537]|772.75||||772.75|14.96|587.29|14.96
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AARP [1000]|AARP [100000]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA [1015]|AETNA [101529]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|16.91|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|234.72|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|163|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|247.76|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|38.13|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|16.91|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|Self-pay|Self-pay|326||||326|65.2|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|TML [1980]|TML [198000]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNICARE [2040]|UNICARE [204000]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|0|247.76|16.91
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||247.76|16.91
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AARP [1000]|AARP [100000]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AETNA [1015]|AETNA [101529]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AMBETTER [2930]|AMBETTER [293000]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|326||||326|17.93|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|234.72|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|163|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|326||||326|247.76|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA [1260]|CIGNA PPO [126025]|326||||326|36.61|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|326||||326|17.93|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|Self-pay|Self-pay|326||||326|65.2|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|TML [1980]|TML [198000]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UNICARE [2040]|UNICARE [204000]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326||247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WEB TPA [2115]|WEB TPA [211500]|326||||326|224.94|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|0|247.76|17.93
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WORKER'S COMP [2125]|TML WC [212537]|326||||326||247.76|17.93
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AARP [1000]|AARP [100000]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA [1015]|AETNA [101529]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMBETTER [2930]|AMBETTER [293000]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|983.94||||983.94|11.56|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|983.94||||983.94|708.44|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|983.94||||983.94|491.97|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|983.94||||983.94|491.97|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|983.94||||983.94|747.79|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA [1260]|CIGNA PPO [126025]|983.94||||983.94|26.05|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|983.94||||983.94|11.56|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|Self-pay|Self-pay|983.94||||983.94|196.79|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|TML [1980]|TML [198000]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNICARE [2040]|UNICARE [204000]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|983.94||||983.94||747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WEB TPA [2115]|WEB TPA [211500]|983.94||||983.94|678.92|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|983.94||||983.94|0|747.79|11.56
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WORKER'S COMP [2125]|TML WC [212537]|983.94||||983.94||747.79|11.56
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AARP [1000]|AARP [100000]|261||||261|9.94|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA [1015]|AETNA [101529]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMBETTER [2930]|AMBETTER [293000]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|261||||261|15.67|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261||||261|187.92|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261||||261|130.5|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261||||261|130.5|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|261||||261|198.36|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA [1260]|CIGNA PPO [126025]|261||||261|35.32|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|261||||261|9.94|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|261||||261|15.67|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|Self-pay|Self-pay|261||||261|52.2|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|TML [1980]|TML [198000]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261||||261|16.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261||||261|9.94|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNICARE [2040]|UNICARE [204000]|261||||261|9.94|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261||||261|9.94|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WEB TPA [2115]|WEB TPA [211500]|261||||261|180.09|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261||||261|0|198.36|9.94
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WORKER'S COMP [2125]|TML WC [212537]|261||||261|9.94|198.36|9.94
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AARP [1000]|AARP [100000]|468.75||||468.75|9.71|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA [1015]|AETNA [101529]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMBETTER [2930]|AMBETTER [293000]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|468.75||||468.75|15.3|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|468.75||||468.75|337.5|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|468.75||||468.75|234.38|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|468.75||||468.75|234.38|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|468.75||||468.75|356.25|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA [1260]|CIGNA PPO [126025]|468.75||||468.75|34.52|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|468.75||||468.75|9.71|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|468.75||||468.75|15.3|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|Self-pay|Self-pay|468.75||||468.75|93.75|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|TML [1980]|TML [198000]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|468.75||||468.75|15.73|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|468.75||||468.75|9.71|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNICARE [2040]|UNICARE [204000]|468.75||||468.75|9.71|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|468.75||||468.75|9.71|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WEB TPA [2115]|WEB TPA [211500]|468.75||||468.75|323.44|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|468.75||||468.75|0|356.25|9.71
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WORKER'S COMP [2125]|TML WC [212537]|468.75||||468.75|9.71|356.25|9.71
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AARP [1000]|AARP [100000]|428||||428|8.86|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA [1015]|AETNA [101529]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMBETTER [2930]|AMBETTER [293000]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|428||||428|13.96|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|428||||428|308.16|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|428||||428|214|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|428||||428|214|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|428||||428|325.28|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA [1260]|CIGNA PPO [126025]|428||||428|31.48|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|428||||428|8.86|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|428||||428|13.96|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|Self-pay|Self-pay|428||||428|85.6|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|TML [1980]|TML [198000]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|428||||428|14.34|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|428||||428|8.86|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNICARE [2040]|UNICARE [204000]|428||||428|8.86|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|428||||428|8.86|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WEB TPA [2115]|WEB TPA [211500]|428||||428|295.32|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|428||||428|0|325.28|8.86
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WORKER'S COMP [2125]|TML WC [212537]|428||||428|8.86|325.28|8.86
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AARP [1000]|AARP [100000]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|19.89|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|475.19|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|330|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|330|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|501.59|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|44.85|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|19.89|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|Self-pay|Self-pay|659.99||||659.99|132|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99|0|501.59|19.89
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||501.59|19.89
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AARP [1000]|AARP [100000]|520.25||||520.25|10.76|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AETNA [1015]|AETNA [101529]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AMBETTER [2930]|AMBETTER [293000]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|520.25||||520.25|16.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|520.25||||520.25|374.58|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|520.25||||520.25|260.13|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|520.25||||520.25|260.13|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|520.25||||520.25|395.39|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA [1260]|CIGNA PPO [126025]|520.25||||520.25|38.23|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|520.25||||520.25|10.76|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|520.25||||520.25|16.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|Self-pay|Self-pay|520.25||||520.25|104.05|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|TML [1980]|TML [198000]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|520.25||||520.25|17.43|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|520.25||||520.25|10.76|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UNICARE [2040]|UNICARE [204000]|520.25||||520.25|10.76|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|520.25||||520.25|10.76|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WEB TPA [2115]|WEB TPA [211500]|520.25||||520.25|358.97|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|520.25||||520.25|0|395.39|10.76
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WORKER'S COMP [2125]|TML WC [212537]|520.25||||520.25|10.76|395.39|10.76
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AARP [1000]|AARP [100000]|527.75||||527.75|10.92|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA [1015]|AETNA [101529]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMBETTER [2930]|AMBETTER [293000]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|527.75||||527.75|17.21|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|527.75||||527.75|379.98|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|527.75||||527.75|263.88|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|527.75||||527.75|263.88|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|527.75||||527.75|401.09|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA [1260]|CIGNA PPO [126025]|527.75||||527.75|38.83|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|527.75||||527.75|10.92|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|527.75||||527.75|17.21|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|Self-pay|Self-pay|527.75||||527.75|105.55|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|TML [1980]|TML [198000]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|527.75||||527.75|17.68|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|527.75||||527.75|10.92|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNICARE [2040]|UNICARE [204000]|527.75||||527.75|10.92|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|527.75||||527.75|10.92|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WEB TPA [2115]|WEB TPA [211500]|527.75||||527.75|364.15|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|527.75||||527.75|0|401.09|10.92
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WORKER'S COMP [2125]|TML WC [212537]|527.75||||527.75|10.92|401.09|10.92
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AARP [1000]|AARP [100000]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AETNA [1015]|AETNA [101529]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AMBETTER [2930]|AMBETTER [293000]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|573.5||||573.5|18.71|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|573.5||||573.5|412.92|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|573.5||||573.5|286.75|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|573.5||||573.5|286.75|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|573.5||||573.5|435.86|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|CIGNA [1260]|CIGNA PPO [126025]|573.5||||573.5|42.2|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|573.5||||573.5|18.71|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|Self-pay|Self-pay|573.5||||573.5|114.7|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|TML [1980]|TML [198000]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|UNICARE [2040]|UNICARE [204000]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|573.5||||573.5||435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|WEB TPA [2115]|WEB TPA [211500]|573.5||||573.5|395.72|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|573.5||||573.5|0|435.86|18.71
30286777|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA|1|WORKER'S COMP [2125]|TML WC [212537]|573.5||||573.5||435.86|18.71
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AARP [1000]|AARP [100000]|611||||611|13.12|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AETNA [1015]|AETNA [101529]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AMBETTER [2930]|AMBETTER [293000]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|611||||611|20.68|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|611||||611|439.92|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|611||||611|305.5|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|611||||611|305.5|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|611||||611|464.36|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA [1260]|CIGNA PPO [126025]|611||||611|46.64|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|611||||611|13.12|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|611||||611|20.68|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|Self-pay|Self-pay|611||||611|122.2|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|TML [1980]|TML [198000]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|611||||611|21.24|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|611||||611|13.12|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UNICARE [2040]|UNICARE [204000]|611||||611|13.12|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|611||||611|13.12|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WEB TPA [2115]|WEB TPA [211500]|611||||611|421.59|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|611||||611|0|464.36|13.12
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WORKER'S COMP [2125]|TML WC [212537]|611||||611|13.12|464.36|13.12
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AARP [1000]|AARP [100000]|1059.84||||1059.84|20.58|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AETNA [1015]|AETNA [101529]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AMBETTER [2930]|AMBETTER [293000]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1059.84||||1059.84|378.64|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1059.84||||1059.84|763.08|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1059.84||||1059.84|529.92|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1059.84||||1059.84|529.92|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1059.84||||1059.84|805.48|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA [1260]|CIGNA PPO [126025]|1059.84||||1059.84|90.13|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1059.84||||1059.84|20.58|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1059.84||||1059.84|378.64|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|Self-pay|Self-pay|1059.84||||1059.84|211.97|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|TML [1980]|TML [198000]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1059.84||||1059.84|412.49|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1059.84||||1059.84|20.58|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UNICARE [2040]|UNICARE [204000]|1059.84||||1059.84|20.58|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1059.84||||1059.84|20.58|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WEB TPA [2115]|WEB TPA [211500]|1059.84||||1059.84|731.29|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1059.84||||1059.84|0|805.48|20.58
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WORKER'S COMP [2125]|TML WC [212537]|1059.84||||1059.84|20.58|805.48|20.58
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AARP [1000]|AARP [100000]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA [1015]|AETNA [101529]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMBETTER [2930]|AMBETTER [293000]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|351.36||||351.36|72.36|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351.36||||351.36|252.98|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351.36||||351.36|175.68|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351.36||||351.36|175.68|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|351.36||||351.36|267.03|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA [1260]|CIGNA PPO [126025]|351.36||||351.36|15.76|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|351.36||||351.36|72.36|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|Self-pay|Self-pay|351.36||||351.36|70.27|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|TML [1980]|TML [198000]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNICARE [2040]|UNICARE [204000]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351.36||||351.36||267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WEB TPA [2115]|WEB TPA [211500]|351.36||||351.36|242.44|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351.36||||351.36|0|267.03|15.76
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WORKER'S COMP [2125]|TML WC [212537]|351.36||||351.36||267.03|15.76
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AARP [1000]|AARP [100000]|351.36||||351.36|4.72|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA [1015]|AETNA [101529]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMBETTER [2930]|AMBETTER [293000]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|351.36||||351.36|193.91|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351.36||||351.36|252.98|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351.36||||351.36|175.68|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351.36||||351.36|175.68|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|351.36||||351.36|267.03|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA [1260]|CIGNA PPO [126025]|351.36||||351.36|16.78|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|351.36||||351.36|4.72|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|351.36||||351.36|193.91|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|Self-pay|Self-pay|351.36||||351.36|70.27|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|TML [1980]|TML [198000]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351.36||||351.36|7.63|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351.36||||351.36|4.72|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNICARE [2040]|UNICARE [204000]|351.36||||351.36|4.72|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351.36||||351.36|4.72|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WEB TPA [2115]|WEB TPA [211500]|351.36||||351.36|242.44|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351.36||||351.36|0|267.03|4.72
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WORKER'S COMP [2125]|TML WC [212537]|351.36||||351.36|4.72|267.03|4.72
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AARP [1000]|AARP [100000]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA [1015]|AETNA [101529]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMBETTER [2930]|AMBETTER [293000]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|351.36||||351.36|193.91|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351.36||||351.36|252.98|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351.36||||351.36|175.68|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351.36||||351.36|175.68|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|351.36||||351.36|267.03|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA [1260]|CIGNA PPO [126025]|351.36||||351.36|15.16|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|351.36||||351.36|193.91|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|Self-pay|Self-pay|351.36||||351.36|70.27|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|TML [1980]|TML [198000]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNICARE [2040]|UNICARE [204000]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351.36||||351.36||267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WEB TPA [2115]|WEB TPA [211500]|351.36||||351.36|242.44|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351.36||||351.36|0|267.03|15.16
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WORKER'S COMP [2125]|TML WC [212537]|351.36||||351.36||267.03|15.16
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AARP [1000]|AARP [100000]|182.88||||182.88|2.46|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA [1015]|AETNA [101529]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMBETTER [2930]|AMBETTER [293000]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|182.88||||182.88|145.54|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.88||||182.88|131.67|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.88||||182.88|91.44|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.88||||182.88|91.44|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|182.88||||182.88|138.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA [1260]|CIGNA PPO [126025]|182.88||||182.88|8.77|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|182.88||||182.88|2.46|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|182.88||||182.88|145.54|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|Self-pay|Self-pay|182.88||||182.88|36.58|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|TML [1980]|TML [198000]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.88||||182.88|3.99|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.88||||182.88|2.46|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNICARE [2040]|UNICARE [204000]|182.88||||182.88|2.46|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.88||||182.88|2.46|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WEB TPA [2115]|WEB TPA [211500]|182.88||||182.88|126.19|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.88||||182.88|0|145.54|2.46
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WORKER'S COMP [2125]|TML WC [212537]|182.88||||182.88|2.46|145.54|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AARP [1000]|AARP [100000]|182.88||||182.88|2.46|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA [1015]|AETNA [101529]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMBETTER [2930]|AMBETTER [293000]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|182.88||||182.88|43.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.88||||182.88|131.67|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.88||||182.88|91.44|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.88||||182.88|91.44|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|182.88||||182.88|138.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA [1260]|CIGNA PPO [126025]|182.88||||182.88|8.77|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|182.88||||182.88|2.46|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|182.88||||182.88|43.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|Self-pay|Self-pay|182.88||||182.88|36.58|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|TML [1980]|TML [198000]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.88||||182.88|3.99|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.88||||182.88|2.46|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNICARE [2040]|UNICARE [204000]|182.88||||182.88|2.46|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.88||||182.88|2.46|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WEB TPA [2115]|WEB TPA [211500]|182.88||||182.88|126.19|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.88||||182.88|0|138.99|2.46
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WORKER'S COMP [2125]|TML WC [212537]|182.88||||182.88|2.46|138.99|2.46
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AARP [1000]|AARP [100000]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AETNA [1015]|AETNA [101529]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AMBETTER [2930]|AMBETTER [293000]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|234.72||||234.72|378.64|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234.72||||234.72|169|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234.72||||234.72|117.36|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234.72||||234.72|117.36|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|234.72||||234.72|178.39|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|CIGNA [1260]|CIGNA PPO [126025]|234.72||||234.72|11.22|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|234.72||||234.72|378.64|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|Self-pay|Self-pay|234.72||||234.72|46.94|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|TML [1980]|TML [198000]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|UNICARE [2040]|UNICARE [204000]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234.72||||234.72||378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|WEB TPA [2115]|WEB TPA [211500]|234.72||||234.72|161.96|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234.72||||234.72|0|378.64|11.22
30286905|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPING RBC ANTIGEN OTH/THAN ABO/RH D EA|1|WORKER'S COMP [2125]|TML WC [212537]|234.72||||234.72||378.64|11.22
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AARP [1000]|AARP [100000]|432||||432|10.78|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA [1015]|AETNA [101529]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMBETTER [2930]|AMBETTER [293000]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|432||||432|193.91|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432|311.04|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432|216|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432|216|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|432||||432|328.32|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|432||||432|73.18|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|432||||432|10.78|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|432||||432|193.91|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|Self-pay|Self-pay|432||||432|86.4|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|TML [1980]|TML [198000]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|168.13|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432|10.78|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNICARE [2040]|UNICARE [204000]|432||||432|10.78|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432|10.78|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WEB TPA [2115]|WEB TPA [211500]|432||||432|298.08|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432||||432|0|328.32|10.78
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|432||||432|10.78|328.32|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AARP [1000]|AARP [100000]|609.12||||609.12|10.78|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA [1015]|AETNA [101529]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMBETTER [2930]|AMBETTER [293000]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|609.12||||609.12|193.91|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.12||||609.12|438.57|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.12||||609.12|304.56|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.12||||609.12|304.56|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|609.12||||609.12|462.93|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA [1260]|CIGNA PPO [126025]|609.12||||609.12|58.55|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|609.12||||609.12|10.78|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|609.12||||609.12|193.91|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|Self-pay|Self-pay|609.12||||609.12|121.82|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|TML [1980]|TML [198000]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.12||||609.12|237.07|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.12||||609.12|10.78|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNICARE [2040]|UNICARE [204000]|609.12||||609.12|10.78|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.12||||609.12|10.78|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WEB TPA [2115]|WEB TPA [211500]|609.12||||609.12|420.29|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.12||||609.12|0|462.93|10.78
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WORKER'S COMP [2125]|TML WC [212537]|609.12||||609.12|10.78|462.93|10.78
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AARP [1000]|AARP [100000]|216.66||||216.66|2.84|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA [1015]|AETNA [101529]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMBETTER [2930]|AMBETTER [293000]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|216.66||||216.66|4.94|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216.66||||216.66|156|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216.66||||216.66|108.33|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216.66||||216.66|108.33|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|216.66||||216.66|164.66|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA [1260]|CIGNA PPO [126025]|216.66||||216.66|10.06|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|216.66||||216.66|2.84|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|216.66||||216.66|4.94|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|Self-pay|Self-pay|216.66||||216.66|43.33|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|TML [1980]|TML [198000]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216.66||||216.66|5.07|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216.66||||216.66|2.84|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNICARE [2040]|UNICARE [204000]|216.66||||216.66|2.84|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216.66||||216.66|2.84|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WEB TPA [2115]|WEB TPA [211500]|216.66||||216.66|149.5|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216.66||||216.66|0|164.66|2.84
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WORKER'S COMP [2125]|TML WC [212537]|216.66||||216.66|2.84|164.66|2.84
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AARP [1000]|AARP [100000]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AETNA [1015]|AETNA [101529]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AMBETTER [2930]|AMBETTER [293000]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.04||||149.04|9.1|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.04||||149.04|107.31|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.04||||149.04|74.52|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.04||||149.04|74.52|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.04||||149.04|113.27|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|CIGNA [1260]|CIGNA PPO [126025]|149.04||||149.04|6.95|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.04||||149.04|9.1|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|Self-pay|Self-pay|149.04||||149.04|29.81|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|TML [1980]|TML [198000]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|UNICARE [2040]|UNICARE [204000]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.04||||149.04||113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|WEB TPA [2115]|WEB TPA [211500]|149.04||||149.04|102.84|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.04||||149.04|0|113.27|6.95
30585013|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT SPUN|1|WORKER'S COMP [2125]|TML WC [212537]|149.04||||149.04||113.27|6.95
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AARP [1000]|AARP [100000]|149.04||||149.04|1.96|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA [1015]|AETNA [101529]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMBETTER [2930]|AMBETTER [293000]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.04||||149.04|3.08|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.04||||149.04|107.31|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.04||||149.04|74.52|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.04||||149.04|74.52|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.04||||149.04|113.27|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA [1260]|CIGNA PPO [126025]|149.04||||149.04|6.95|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.04||||149.04|1.96|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.04||||149.04|3.08|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|Self-pay|Self-pay|149.04||||149.04|29.81|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|TML [1980]|TML [198000]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.04||||149.04|3.16|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.04||||149.04|1.96|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNICARE [2040]|UNICARE [204000]|149.04||||149.04|1.96|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.04||||149.04|1.96|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WEB TPA [2115]|WEB TPA [211500]|149.04||||149.04|102.84|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.04||||149.04|0|113.27|1.96
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WORKER'S COMP [2125]|TML WC [212537]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AARP [1000]|AARP [100000]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA [1015]|AETNA [101529]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMBETTER [2930]|AMBETTER [293000]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.04||||149.04|3.08|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.04||||149.04|107.31|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.04||||149.04|74.52|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.04||||149.04|74.52|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.04||||149.04|113.27|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA [1260]|CIGNA PPO [126025]|149.04||||149.04|6.95|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.04||||149.04|3.08|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|Self-pay|Self-pay|149.04||||149.04|29.81|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|TML [1980]|TML [198000]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.04||||149.04|3.16|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNICARE [2040]|UNICARE [204000]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.04||||149.04|1.96|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WEB TPA [2115]|WEB TPA [211500]|149.04||||149.04|102.84|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.04||||149.04|0|113.27|1.96
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WORKER'S COMP [2125]|TML WC [212537]|149.04||||149.04|1.96|113.27|1.96
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AARP [1000]|AARP [100000]|408.48||||408.48|6.41|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA [1015]|AETNA [101529]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMBETTER [2930]|AMBETTER [293000]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408.48||||408.48|10.1|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.48||||408.48|294.11|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.48||||408.48|204.24|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.48||||408.48|204.24|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408.48||||408.48|310.44|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|408.48||||408.48|22.77|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408.48||||408.48|6.41|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408.48||||408.48|10.1|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|Self-pay|Self-pay|408.48||||408.48|81.7|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|TML [1980]|TML [198000]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.48||||408.48|10.38|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.48||||408.48|6.41|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNICARE [2040]|UNICARE [204000]|408.48||||408.48|6.41|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.48||||408.48|6.41|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WEB TPA [2115]|WEB TPA [211500]|408.48||||408.48|281.85|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.48||||408.48|0|310.44|6.41
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|408.48||||408.48|6.41|310.44|6.41
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AARP [1000]|AARP [100000]|408.48||||408.48|5.33|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA [1015]|AETNA [101529]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMBETTER [2930]|AMBETTER [293000]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|408.48||||408.48|8.41|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.48||||408.48|294.11|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.48||||408.48|204.24|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.48||||408.48|204.24|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|408.48||||408.48|310.44|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|408.48||||408.48|18.97|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|408.48||||408.48|5.33|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|408.48||||408.48|8.41|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|Self-pay|Self-pay|408.48||||408.48|81.7|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|TML [1980]|TML [198000]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.48||||408.48|8.63|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.48||||408.48|5.33|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNICARE [2040]|UNICARE [204000]|408.48||||408.48|5.33|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.48||||408.48|5.33|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WEB TPA [2115]|WEB TPA [211500]|408.48||||408.48|281.85|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.48||||408.48|0|310.44|5.33
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|408.48||||408.48|5.33|310.44|5.33
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AARP [1000]|AARP [100000]|270.48||||270.48|3.55|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AETNA [1015]|AETNA [101529]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AMBETTER [2930]|AMBETTER [293000]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|270.48||||270.48|5.6|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270.48||||270.48|194.75|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270.48||||270.48|135.24|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270.48||||270.48|135.24|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|270.48||||270.48|205.56|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA [1260]|CIGNA PPO [126025]|270.48||||270.48|12.61|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|270.48||||270.48|3.55|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|270.48||||270.48|5.6|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|Self-pay|Self-pay|270.48||||270.48|54.1|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|TML [1980]|TML [198000]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270.48||||270.48|5.76|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270.48||||270.48|3.55|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UNICARE [2040]|UNICARE [204000]|270.48||||270.48|3.55|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270.48||||270.48|3.55|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WEB TPA [2115]|WEB TPA [211500]|270.48||||270.48|186.63|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270.48||||270.48|0|205.56|3.55
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WORKER'S COMP [2125]|TML WC [212537]|270.48||||270.48|3.55|205.56|3.55
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AARP [1000]|AARP [100000]|12||||12|3.3|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA [1015]|AETNA [101529]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMBETTER [2930]|AMBETTER [293000]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12||||12|5.19|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12||||12|8.64|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12||||12|6|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12||||12|6|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12||||12|9.12|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|12||||12|11.72|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12||||12|3.3|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12||||12|5.19|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|Self-pay|Self-pay|12||||12|2.4|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|TML [1980]|TML [198000]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12||||12|5.33|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12||||12|3.3|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNICARE [2040]|UNICARE [204000]|12||||12|3.3|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12||||12|3.3|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WEB TPA [2115]|WEB TPA [211500]|12||||12|8.28|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12||||12|0|11.72|2.4
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|12||||12|3.3|11.72|2.4
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AARP [1000]|AARP [100000]|2109.6||||2109.6|22.86|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA [1015]|AETNA [101529]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMBETTER [2930]|AMBETTER [293000]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2109.6||||2109.6|853|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2109.6||||2109.6|1518.91|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2109.6||||2109.6|1054.8|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2109.6||||2109.6|1054.8|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2109.6||||2109.6|1603.3|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA [1260]|CIGNA PPO [126025]|2109.6||||2109.6|109.4|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2109.6||||2109.6|22.86|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2109.6||||2109.6|853|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|Self-pay|Self-pay|2109.6||||2109.6|421.92|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|TML [1980]|TML [198000]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2109.6||||2109.6|821.06|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2109.6||||2109.6|22.86|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNICARE [2040]|UNICARE [204000]|2109.6||||2109.6|22.86|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2109.6||||2109.6|22.86|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WEB TPA [2115]|WEB TPA [211500]|2109.6||||2109.6|1455.62|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2109.6||||2109.6|0|1603.3|22.86
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WORKER'S COMP [2125]|TML WC [212537]|2109.6||||2109.6|22.86|1603.3|22.86
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AARP [1000]|AARP [100000]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA [1015]|AETNA [101529]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMBETTER [2930]|AMBETTER [293000]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|819.72||||819.72|16.87|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|819.72||||819.72|590.2|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|819.72||||819.72|409.86|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|819.72||||819.72|409.86|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|819.72||||819.72|622.99|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA [1260]|CIGNA PPO [126025]|819.72||||819.72|38.07|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|819.72||||819.72|16.87|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|Self-pay|Self-pay|819.72||||819.72|163.94|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|TML [1980]|TML [198000]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNICARE [2040]|UNICARE [204000]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|819.72||||819.72||622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WEB TPA [2115]|WEB TPA [211500]|819.72||||819.72|565.61|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|819.72||||819.72|0|622.99|16.87
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WORKER'S COMP [2125]|TML WC [212537]|819.72||||819.72||622.99|16.87
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AARP [1000]|AARP [100000]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA [1015]|AETNA [101529]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMBETTER [2930]|AMBETTER [293000]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1113.66||||1113.66|22.95|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1113.66||||1113.66|801.84|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1113.66||||1113.66|556.83|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1113.66||||1113.66|556.83|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1113.66||||1113.66|846.38|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA [1260]|CIGNA PPO [126025]|1113.66||||1113.66|51.74|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1113.66||||1113.66|22.95|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|Self-pay|Self-pay|1113.66||||1113.66|222.73|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|TML [1980]|TML [198000]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNICARE [2040]|UNICARE [204000]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1113.66||||1113.66||846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WEB TPA [2115]|WEB TPA [211500]|1113.66||||1113.66|768.43|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1113.66||||1113.66|0|846.38|22.95
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WORKER'S COMP [2125]|TML WC [212537]|1113.66||||1113.66||846.38|22.95
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|23.27|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|813.76|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|565.11|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|565.11|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|858.97|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|23.27|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22|0|858.97|23.27
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||858.97|23.27
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AARP [1000]|AARP [100000]|478.86||||478.86|14.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA [1015]|AETNA [101529]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMBETTER [2930]|AMBETTER [293000]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.86||||478.86|23.27|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.86||||478.86|344.78|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.86||||478.86|239.43|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.86||||478.86|239.43|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.86||||478.86|363.93|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA [1260]|CIGNA PPO [126025]|478.86||||478.86|52.46|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.86||||478.86|14.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.86||||478.86|23.27|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|Self-pay|Self-pay|478.86||||478.86|95.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|TML [1980]|TML [198000]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.86||||478.86|23.91|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.86||||478.86|14.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNICARE [2040]|UNICARE [204000]|478.86||||478.86|14.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.86||||478.86|14.77|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WEB TPA [2115]|WEB TPA [211500]|478.86||||478.86|330.41|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.86||||478.86|0|363.93|14.77
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WORKER'S COMP [2125]|TML WC [212537]|478.86||||478.86|14.77|363.93|14.77
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AARP [1000]|AARP [100000]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AETNA [1015]|AETNA [101529]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AMBETTER [2930]|AMBETTER [293000]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|419.52||||419.52|26.55|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419.52||||419.52|302.05|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419.52||||419.52|209.76|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419.52||||419.52|209.76|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|419.52||||419.52|318.84|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|CIGNA [1260]|CIGNA PPO [126025]|419.52||||419.52|59.84|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|419.52||||419.52|26.55|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|Self-pay|Self-pay|419.52||||419.52|83.9|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|TML [1980]|TML [198000]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|UNICARE [2040]|UNICARE [204000]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419.52||||419.52||318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|WEB TPA [2115]|WEB TPA [211500]|419.52||||419.52|289.47|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419.52||||419.52|0|318.84|26.55
30585244|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII RELATED AG|1|WORKER'S COMP [2125]|TML WC [212537]|419.52||||419.52||318.84|26.55
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AARP [1000]|AARP [100000]|449.88||||449.88|18.92|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|29.82|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|323.91|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|224.94|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|224.94|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|341.91|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|67.23|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88|18.92|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|29.82|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|Self-pay|Self-pay|449.88||||449.88|89.98|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88|30.64|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88|18.92|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88|18.92|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88|18.92|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449.88||||449.88|0|341.91|18.92
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88|18.92|341.91|18.92
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AARP [1000]|AARP [100000]|1200.6||||1200.6|15.7|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AETNA [1015]|AETNA [101529]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AMBETTER [2930]|AMBETTER [293000]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1200.6||||1200.6|24.75|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1200.6||||1200.6|864.43|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1200.6||||1200.6|600.3|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1200.6||||1200.6|600.3|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1200.6||||1200.6|912.46|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA [1260]|CIGNA PPO [126025]|1200.6||||1200.6|55.81|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1200.6||||1200.6|15.7|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1200.6||||1200.6|24.75|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|Self-pay|Self-pay|1200.6||||1200.6|240.12|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|TML [1980]|TML [198000]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1200.6||||1200.6|25.42|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1200.6||||1200.6|15.7|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UNICARE [2040]|UNICARE [204000]|1200.6||||1200.6|15.7|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1200.6||||1200.6|15.7|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WEB TPA [2115]|WEB TPA [211500]|1200.6||||1200.6|828.41|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1200.6||||1200.6|0|912.46|15.7
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WORKER'S COMP [2125]|TML WC [212537]|1200.6||||1200.6|15.7|912.46|15.7
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|23.27|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|813.76|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|565.11|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|565.11|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|858.97|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|23.27|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22|0|858.97|23.27
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AARP [1000]|AARP [100000]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA [1015]|AETNA [101529]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMBETTER [2930]|AMBETTER [293000]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.22||||1130.22|23.27|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.22||||1130.22|813.76|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.22||||1130.22|565.11|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.22||||1130.22|565.11|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.22||||1130.22|858.97|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA [1260]|CIGNA PPO [126025]|1130.22||||1130.22|52.46|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.22||||1130.22|23.27|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|Self-pay|Self-pay|1130.22||||1130.22|226.04|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|TML [1980]|TML [198000]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNICARE [2040]|UNICARE [204000]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.22||||1130.22||858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WEB TPA [2115]|WEB TPA [211500]|1130.22||||1130.22|779.85|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1130.22||||1130.22|0|858.97|23.27
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WORKER'S COMP [2125]|TML WC [212537]|1130.22||||1130.22||858.97|23.27
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AARP [1000]|AARP [100000]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA [1015]|AETNA [101529]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.43||||594.43|14.05|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.43||||594.43|427.99|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.43||||594.43|297.22|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.43||||594.43|297.22|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.43||||594.43|451.77|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|594.43||||594.43|31.68|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.43||||594.43|14.05|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|Self-pay|Self-pay|594.43||||594.43|118.89|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|TML [1980]|TML [198000]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNICARE [2040]|UNICARE [204000]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.43||||594.43||451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|594.43||||594.43|410.16|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594.43||||594.43|0|451.77|14.05
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|594.43||||594.43||451.77|14.05
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AARP [1000]|AARP [100000]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA [1015]|AETNA [101529]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|760.03||||760.03|17.99|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|760.03||||760.03|547.22|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|760.03||||760.03|380.02|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|760.03||||760.03|380.02|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|760.03||||760.03|577.62|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|760.03||||760.03|40.55|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|760.03||||760.03|17.99|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|Self-pay|Self-pay|760.03||||760.03|152.01|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|TML [1980]|TML [198000]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|760.03||||760.03||577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|760.03||||760.03|524.42|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|760.03||||760.03|0|577.62|17.99
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|760.03||||760.03||577.62|17.99
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AARP [1000]|AARP [100000]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA [1015]|AETNA [101529]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMBETTER [2930]|AMBETTER [293000]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|812.82||||812.82|16.73|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|812.82||||812.82|585.23|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|812.82||||812.82|406.41|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|812.82||||812.82|406.41|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|812.82||||812.82|617.74|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA [1260]|CIGNA PPO [126025]|812.82||||812.82|37.7|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|812.82||||812.82|16.73|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|Self-pay|Self-pay|812.82||||812.82|162.56|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|TML [1980]|TML [198000]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNICARE [2040]|UNICARE [204000]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|812.82||||812.82||617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WEB TPA [2115]|WEB TPA [211500]|812.82||||812.82|560.85|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|812.82||||812.82|0|617.74|16.73
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WORKER'S COMP [2125]|TML WC [212537]|812.82||||812.82||617.74|16.73
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AARP [1000]|AARP [100000]|325.68||||325.68|3.51|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AETNA [1015]|AETNA [101529]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMBETTER [2930]|AMBETTER [293000]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|325.68||||325.68|5.56|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|325.68||||325.68|234.49|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|325.68||||325.68|162.84|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|325.68||||325.68|162.84|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|325.68||||325.68|247.52|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|CIGNA [1260]|CIGNA PPO [126025]|325.68||||325.68|12.48|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|325.68||||325.68|3.51|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|325.68||||325.68|5.56|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|Self-pay|Self-pay|325.68||||325.68|65.14|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|TML [1980]|TML [198000]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|325.68||||325.68|5.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|325.68||||325.68|3.51|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UNICARE [2040]|UNICARE [204000]|325.68||||325.68|3.51|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|325.68||||325.68|3.51|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WEB TPA [2115]|WEB TPA [211500]|325.68||||325.68|224.72|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|325.68||||325.68|0|247.52|3.51
30585347|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG TIME ACTIVATED|1|WORKER'S COMP [2125]|TML WC [212537]|325.68||||325.68|3.51|247.52|3.51
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AARP [1000]|AARP [100000]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA [1015]|AETNA [101529]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMBETTER [2930]|AMBETTER [293000]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|434.7||||434.7|8.96|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|434.7||||434.7|312.98|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|434.7||||434.7|217.35|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|434.7||||434.7|217.35|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|434.7||||434.7|330.37|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA [1260]|CIGNA PPO [126025]|434.7||||434.7|20.19|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|434.7||||434.7|8.96|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|Self-pay|Self-pay|434.7||||434.7|86.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|TML [1980]|TML [198000]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNICARE [2040]|UNICARE [204000]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|434.7||||434.7||330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WEB TPA [2115]|WEB TPA [211500]|434.7||||434.7|299.94|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|434.7||||434.7|0|330.37|8.96
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WORKER'S COMP [2125]|TML WC [212537]|434.7||||434.7||330.37|8.96
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AARP [1000]|AARP [100000]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|12.64|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|323.91|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|224.94|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|224.94|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|341.91|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|20.92|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|12.64|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|Self-pay|Self-pay|449.88||||449.88|89.98|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88||341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449.88||||449.88|0|341.91|12.64
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88||341.91|12.64
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AARP [1000]|AARP [100000]|449.88||||449.88|8.39|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|13.23|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|323.91|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|224.94|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|224.94|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|341.91|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|29.86|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88|8.39|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|13.23|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|Self-pay|Self-pay|449.88||||449.88|89.98|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88|13.59|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88|8.39|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88|8.39|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88|8.39|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449.88||||449.88|0|341.91|8.39
30585379|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER QN|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88|8.39|341.91|8.39
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AARP [1000]|AARP [100000]|535.44||||535.44|7.01|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA [1015]|AETNA [101529]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMBETTER [2930]|AMBETTER [293000]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|535.44||||535.44|12.64|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|535.44||||535.44|385.52|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|535.44||||535.44|267.72|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|535.44||||535.44|267.72|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|535.44||||535.44|406.93|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA [1260]|CIGNA PPO [126025]|535.44||||535.44|24.89|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|535.44||||535.44|7.01|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|535.44||||535.44|12.64|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|Self-pay|Self-pay|535.44||||535.44|107.09|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|TML [1980]|TML [198000]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|535.44||||535.44|12.97|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|535.44||||535.44|7.01|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNICARE [2040]|UNICARE [204000]|535.44||||535.44|7.01|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|535.44||||535.44|7.01|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WEB TPA [2115]|WEB TPA [211500]|535.44||||535.44|369.45|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|535.44||||535.44|0|406.93|7.01
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WORKER'S COMP [2125]|TML WC [212537]|535.44||||535.44|7.01|406.93|7.01
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AARP [1000]|AARP [100000]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA [1015]|AETNA [101529]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMBETTER [2930]|AMBETTER [293000]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|314||||314|40.12|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|314||||314|226.08|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|314||||314|157|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|314||||314|157|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|314||||314|238.64|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA [1260]|CIGNA PPO [126025]|314||||314|67.23|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|314||||314|40.12|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|Self-pay|Self-pay|314||||314|62.8|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|TML [1980]|TML [198000]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNICARE [2040]|UNICARE [204000]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|314||||314||238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WEB TPA [2115]|WEB TPA [211500]|314||||314|216.66|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|314||||314|0|238.64|40.12
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WORKER'S COMP [2125]|TML WC [212537]|314||||314||238.64|40.12
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AARP [1000]|AARP [100000]|598||||598|10.8|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA [1015]|AETNA [101529]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMBETTER [2930]|AMBETTER [293000]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|598||||598|17.02|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|598||||598|430.56|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|598||||598|299|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|598||||598|299|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|598||||598|454.48|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA [1260]|CIGNA PPO [126025]|598||||598|38.36|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|598||||598|10.8|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|598||||598|17.02|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|Self-pay|Self-pay|598||||598|119.6|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|TML [1980]|TML [198000]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|598||||598|17.49|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|598||||598|10.8|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNICARE [2040]|UNICARE [204000]|598||||598|10.8|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|598||||598|10.8|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WEB TPA [2115]|WEB TPA [211500]|598||||598|412.62|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|598||||598|0|454.48|10.8
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WORKER'S COMP [2125]|TML WC [212537]|598||||598|10.8|454.48|10.8
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AARP [1000]|AARP [100000]|1355.16||||1355.16|17.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA [1015]|AETNA [101529]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMBETTER [2930]|AMBETTER [293000]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1355.16||||1355.16|32.38|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1355.16||||1355.16|975.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1355.16||||1355.16|677.58|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1355.16||||1355.16|677.58|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1355.16||||1355.16|1029.92|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA [1260]|CIGNA PPO [126025]|1355.16||||1355.16|62.99|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1355.16||||1355.16|17.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1355.16||||1355.16|32.38|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|Self-pay|Self-pay|1355.16||||1355.16|271.03|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|TML [1980]|TML [198000]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1355.16||||1355.16|33.26|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1355.16||||1355.16|17.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNICARE [2040]|UNICARE [204000]|1355.16||||1355.16|17.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1355.16||||1355.16|17.72|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WEB TPA [2115]|WEB TPA [211500]|1355.16||||1355.16|935.06|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1355.16||||1355.16|0|1029.92|17.72
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WORKER'S COMP [2125]|TML WC [212537]|1355.16||||1355.16|17.72|1029.92|17.72
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AARP [1000]|AARP [100000]|156.5||||156.5|3.24|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA [1015]|AETNA [101529]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMBETTER [2930]|AMBETTER [293000]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|156.5||||156.5|5.58|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156.5||||156.5|112.68|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156.5||||156.5|78.25|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156.5||||156.5|78.25|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|156.5||||156.5|118.94|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA [1260]|CIGNA PPO [126025]|156.5||||156.5|11.52|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|156.5||||156.5|3.24|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|156.5||||156.5|5.58|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|Self-pay|Self-pay|156.5||||156.5|31.3|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|TML [1980]|TML [198000]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156.5||||156.5|5.72|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156.5||||156.5|3.24|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNICARE [2040]|UNICARE [204000]|156.5||||156.5|3.24|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156.5||||156.5|3.24|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WEB TPA [2115]|WEB TPA [211500]|156.5||||156.5|107.99|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156.5||||156.5|0|118.94|3.24
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WORKER'S COMP [2125]|TML WC [212537]|156.5||||156.5|3.24|118.94|3.24
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AARP [1000]|AARP [100000]|441.6||||441.6|7.9|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA [1015]|AETNA [101529]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMBETTER [2930]|AMBETTER [293000]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|441.6||||441.6|12.45|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|441.6||||441.6|317.95|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|441.6||||441.6|220.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|441.6||||441.6|220.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|441.6||||441.6|335.62|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA [1260]|CIGNA PPO [126025]|441.6||||441.6|28.07|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|441.6||||441.6|7.9|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|441.6||||441.6|12.45|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|Self-pay|Self-pay|441.6||||441.6|88.32|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|TML [1980]|TML [198000]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|441.6||||441.6|12.8|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|441.6||||441.6|7.9|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNICARE [2040]|UNICARE [204000]|441.6||||441.6|7.9|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|441.6||||441.6|7.9|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WEB TPA [2115]|WEB TPA [211500]|441.6||||441.6|304.7|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|441.6||||441.6|0|335.62|7.9
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WORKER'S COMP [2125]|TML WC [212537]|441.6||||441.6|7.9|335.62|7.9
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AARP [1000]|AARP [100000]|223.56||||223.56|2.23|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA [1015]|AETNA [101529]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMBETTER [2930]|AMBETTER [293000]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|223.56||||223.56|3.51|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223.56||||223.56|160.96|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223.56||||223.56|111.78|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223.56||||223.56|111.78|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|223.56||||223.56|169.91|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA [1260]|CIGNA PPO [126025]|223.56||||223.56|7.91|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|223.56||||223.56|2.23|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|223.56||||223.56|3.51|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|Self-pay|Self-pay|223.56||||223.56|44.71|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|TML [1980]|TML [198000]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223.56||||223.56|3.61|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223.56||||223.56|2.23|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNICARE [2040]|UNICARE [204000]|223.56||||223.56|2.23|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223.56||||223.56|2.23|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WEB TPA [2115]|WEB TPA [211500]|223.56||||223.56|154.26|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223.56||||223.56|0|169.91|2.23
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WORKER'S COMP [2125]|TML WC [212537]|223.56||||223.56|2.23|169.91|2.23
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AARP [1000]|AARP [100000]|239.25||||239.25|4.95|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA [1015]|AETNA [101529]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMBETTER [2930]|AMBETTER [293000]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|239.25||||239.25|7.81|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239.25||||239.25|172.26|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239.25||||239.25|119.63|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239.25||||239.25|119.63|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|239.25||||239.25|181.83|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA [1260]|CIGNA PPO [126025]|239.25||||239.25|17.61|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|239.25||||239.25|4.95|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|239.25||||239.25|7.81|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|Self-pay|Self-pay|239.25||||239.25|47.85|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|TML [1980]|TML [198000]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239.25||||239.25|8.03|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239.25||||239.25|4.95|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNICARE [2040]|UNICARE [204000]|239.25||||239.25|4.95|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239.25||||239.25|4.95|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WEB TPA [2115]|WEB TPA [211500]|239.25||||239.25|165.08|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239.25||||239.25|0|181.83|4.95
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WORKER'S COMP [2125]|TML WC [212537]|239.25||||239.25|4.95|181.83|4.95
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AARP [1000]|AARP [100000]|154||||154|30.8|117.04|30.8
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]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AETNA [1015]|AETNA [101529]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMBETTER [2930]|AMBETTER [293000]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154|81.61|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|154||||154|66.72|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|154||||154|81.61|117.04|30.8
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]|154||||154|0|117.04|30.8
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]|154||||154|110.88|117.04|30.8
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]|154||||154|77|117.04|30.8
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]|154||||154|77|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|154||||154|117.04|117.04|30.8
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]|154||||154|81.61|117.04|30.8
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]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|154||||154|106.26|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA [1260]|CIGNA PPO [126025]|154||||154|61.6|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|154||||154|30.8|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|154||||154|66.72|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|154||||154|106.26|117.04|30.8
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]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154|81.61|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|0|117.04|30.8
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]|154||||154|81.61|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154|81.61|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|Self-pay|Self-pay|154||||154|30.8|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|TML [1980]|TML [198000]|154||||154|106.26|117.04|30.8
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]|154||||154|81.61|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154|30.8|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNICARE [2040]|UNICARE [204000]|154||||154|30.8|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154|30.8|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WEB TPA [2115]|WEB TPA [211500]|154||||154|106.26|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154|0|117.04|30.8
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]|154||||154|0|117.04|30.8
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WORKER'S COMP [2125]|TML WC [212537]|154||||154|30.8|117.04|30.8
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AARP [1000]|AARP [100000]|434.7||||434.7|5.51|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AETNA [1015]|AETNA [101529]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AMBETTER [2930]|AMBETTER [293000]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|434.7||||434.7|8.68|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|434.7||||434.7|312.98|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|434.7||||434.7|217.35|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|434.7||||434.7|217.35|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|434.7||||434.7|330.37|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA [1260]|CIGNA PPO [126025]|434.7||||434.7|19.56|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|434.7||||434.7|5.51|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|434.7||||434.7|8.68|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|Self-pay|Self-pay|434.7||||434.7|86.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|TML [1980]|TML [198000]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|434.7||||434.7|8.92|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|434.7||||434.7|5.51|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UNICARE [2040]|UNICARE [204000]|434.7||||434.7|5.51|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|434.7||||434.7|5.51|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WEB TPA [2115]|WEB TPA [211500]|434.7||||434.7|299.94|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|434.7||||434.7|0|330.37|5.51
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WORKER'S COMP [2125]|TML WC [212537]|434.7||||434.7|5.51|330.37|5.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AARP [1000]|AARP [100000]|673.44||||673.44|8.51|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA [1015]|AETNA [101529]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMBETTER [2930]|AMBETTER [293000]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|673.44||||673.44|13.42|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|673.44||||673.44|484.88|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|673.44||||673.44|336.72|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|673.44||||673.44|336.72|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|673.44||||673.44|511.81|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA [1260]|CIGNA PPO [126025]|673.44||||673.44|30.29|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|673.44||||673.44|8.51|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|673.44||||673.44|13.42|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|Self-pay|Self-pay|673.44||||673.44|134.69|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|TML [1980]|TML [198000]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|673.44||||673.44|13.79|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|673.44||||673.44|8.51|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNICARE [2040]|UNICARE [204000]|673.44||||673.44|8.51|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|673.44||||673.44|8.51|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WEB TPA [2115]|WEB TPA [211500]|673.44||||673.44|464.67|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|673.44||||673.44|0|511.81|8.51
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WORKER'S COMP [2125]|TML WC [212537]|673.44||||673.44|8.51|511.81|8.51
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AARP [1000]|AARP [100000]|615.48||||615.48|7.78|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA [1015]|AETNA [101529]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMBETTER [2930]|AMBETTER [293000]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|615.48||||615.48|12.27|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|615.48||||615.48|443.15|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|615.48||||615.48|307.74|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|615.48||||615.48|307.74|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|615.48||||615.48|467.76|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA [1260]|CIGNA PPO [126025]|615.48||||615.48|27.67|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|615.48||||615.48|7.78|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|615.48||||615.48|12.27|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|Self-pay|Self-pay|615.48||||615.48|123.1|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|TML [1980]|TML [198000]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|615.48||||615.48|12.61|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|615.48||||615.48|7.78|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNICARE [2040]|UNICARE [204000]|615.48||||615.48|7.78|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|615.48||||615.48|7.78|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WEB TPA [2115]|WEB TPA [211500]|615.48||||615.48|424.68|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|615.48||||615.48|0|467.76|7.78
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WORKER'S COMP [2125]|TML WC [212537]|615.48||||615.48|7.78|467.76|7.78
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AARP [1000]|AARP [100000]|615.48||||615.48|7.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|615.48||||615.48|11.21|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|615.48||||615.48|443.15|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|615.48||||615.48|307.74|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|615.48||||615.48|307.74|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|615.48||||615.48|467.76|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|615.48||||615.48|25.26|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|615.48||||615.48|7.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|615.48||||615.48|11.21|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|Self-pay|Self-pay|615.48||||615.48|123.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|TML [1980]|TML [198000]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|615.48||||615.48|11.51|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|615.48||||615.48|7.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNICARE [2040]|UNICARE [204000]|615.48||||615.48|7.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|615.48||||615.48|7.1|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|615.48||||615.48|424.68|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|615.48||||615.48|0|467.76|7.1
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|615.48||||615.48|7.1|467.76|7.1
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AARP [1000]|AARP [100000]|264.96||||264.96|7.81|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA [1015]|AETNA [101529]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMBETTER [2930]|AMBETTER [293000]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264.96||||264.96|12.31|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264.96||||264.96|190.77|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264.96||||264.96|132.48|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264.96||||264.96|132.48|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264.96||||264.96|201.37|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA [1260]|CIGNA PPO [126025]|264.96||||264.96|27.77|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264.96||||264.96|7.81|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264.96||||264.96|12.31|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|Self-pay|Self-pay|264.96||||264.96|52.99|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|TML [1980]|TML [198000]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264.96||||264.96|12.64|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264.96||||264.96|7.81|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNICARE [2040]|UNICARE [204000]|264.96||||264.96|7.81|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264.96||||264.96|7.81|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WEB TPA [2115]|WEB TPA [211500]|264.96||||264.96|182.82|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264.96||||264.96|0|201.37|7.81
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WORKER'S COMP [2125]|TML WC [212537]|264.96||||264.96|7.81|201.37|7.81
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AARP [1000]|AARP [100000]|383||||383|6.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA [1015]|AETNA [101529]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMBETTER [2930]|AMBETTER [293000]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|383||||383|10.5|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|383||||383|275.76|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|383||||383|191.5|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|383||||383|191.5|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|383||||383|291.08|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA [1260]|CIGNA PPO [126025]|383||||383|23.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|383||||383|6.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|383||||383|10.5|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|Self-pay|Self-pay|383||||383|76.6|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|TML [1980]|TML [198000]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|383||||383|10.8|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|383||||383|6.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNICARE [2040]|UNICARE [204000]|383||||383|6.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|383||||383|6.67|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WEB TPA [2115]|WEB TPA [211500]|383||||383|264.27|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|383||||383|0|291.08|6.67
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WORKER'S COMP [2125]|TML WC [212537]|383||||383|6.67|291.08|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AARP [1000]|AARP [100000]|180.78||||180.78|6.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA [1015]|AETNA [101529]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMBETTER [2930]|AMBETTER [293000]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|180.78||||180.78|10.5|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180.78||||180.78|130.16|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180.78||||180.78|90.39|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180.78||||180.78|90.39|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|180.78||||180.78|137.39|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA [1260]|CIGNA PPO [126025]|180.78||||180.78|23.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|180.78||||180.78|6.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|180.78||||180.78|10.5|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|Self-pay|Self-pay|180.78||||180.78|36.16|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|TML [1980]|TML [198000]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180.78||||180.78|10.8|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180.78||||180.78|6.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNICARE [2040]|UNICARE [204000]|180.78||||180.78|6.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180.78||||180.78|6.67|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WEB TPA [2115]|WEB TPA [211500]|180.78||||180.78|124.74|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180.78||||180.78|0|137.39|6.67
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]|180.78||||180.78|0|137.39|6.67
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WORKER'S COMP [2125]|TML WC [212537]|180.78||||180.78|6.67|137.39|6.67
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AARP [1000]|AARP [100000]|2040.1||||2040.1|5.47|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA [1015]|AETNA [101529]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMBETTER [2930]|AMBETTER [293000]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2040.1||||2040.1|8.62|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2040.1||||2040.1|1468.87|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2040.1||||2040.1|1020.05|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2040.1||||2040.1|1020.05|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2040.1||||2040.1|1550.48|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA [1260]|CIGNA PPO [126025]|2040.1||||2040.1|19.43|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2040.1||||2040.1|5.47|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2040.1||||2040.1|8.62|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|Self-pay|Self-pay|2040.1||||2040.1|408.02|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|TML [1980]|TML [198000]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2040.1||||2040.1|8.86|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2040.1||||2040.1|5.47|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNICARE [2040]|UNICARE [204000]|2040.1||||2040.1|5.47|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2040.1||||2040.1|5.47|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WEB TPA [2115]|WEB TPA [211500]|2040.1||||2040.1|1407.67|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2040.1||||2040.1|0|1550.48|5.47
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WORKER'S COMP [2125]|TML WC [212537]|2040.1||||2040.1|5.47|1550.48|5.47
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AARP [1000]|AARP [100000]|264.96||||264.96|6.66|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA [1015]|AETNA [101529]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMBETTER [2930]|AMBETTER [293000]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264.96||||264.96|10.49|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264.96||||264.96|190.77|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264.96||||264.96|132.48|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264.96||||264.96|132.48|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264.96||||264.96|201.37|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA [1260]|CIGNA PPO [126025]|264.96||||264.96|23.67|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264.96||||264.96|6.66|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264.96||||264.96|10.49|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|Self-pay|Self-pay|264.96||||264.96|52.99|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|TML [1980]|TML [198000]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264.96||||264.96|10.78|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264.96||||264.96|6.66|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNICARE [2040]|UNICARE [204000]|264.96||||264.96|6.66|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264.96||||264.96|6.66|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WEB TPA [2115]|WEB TPA [211500]|264.96||||264.96|182.82|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264.96||||264.96|0|201.37|6.66
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]|264.96||||264.96|0|201.37|6.66
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WORKER'S COMP [2125]|TML WC [212537]|264.96||||264.96|6.66|201.37|6.66
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AARP [1000]|AARP [100000]|528.54||||528.54|6.68|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AETNA [1015]|AETNA [101529]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMBETTER [2930]|AMBETTER [293000]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528.54||||528.54|10.52|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528.54||||528.54|380.55|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528.54||||528.54|264.27|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528.54||||528.54|264.27|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528.54||||528.54|401.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|CIGNA [1260]|CIGNA PPO [126025]|528.54||||528.54|23.73|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528.54||||528.54|6.68|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528.54||||528.54|10.52|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|Self-pay|Self-pay|528.54||||528.54|105.71|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|TML [1980]|TML [198000]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528.54||||528.54|10.81|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528.54||||528.54|6.68|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UNICARE [2040]|UNICARE [204000]|528.54||||528.54|6.68|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528.54||||528.54|6.68|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WEB TPA [2115]|WEB TPA [211500]|528.54||||528.54|364.69|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528.54||||528.54|0|401.69|6.68
30687088|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BACT URINE ISOL&PRSMPTV ID ISOLATE EA|1|WORKER'S COMP [2125]|TML WC [212537]|528.54||||528.54|6.68|401.69|6.68
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AARP [1000]|AARP [100000]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA [1015]|AETNA [101529]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMBETTER [2930]|AMBETTER [293000]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|503.7||||503.7|10.02|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|503.7||||503.7||382.81|10.02
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]|503.7||||503.7|0|382.81|10.02
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]|503.7||||503.7|362.66|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|503.7||||503.7|251.85|382.81|10.02
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]|503.7||||503.7|251.85|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|503.7||||503.7|382.81|382.81|10.02
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]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|503.7||||503.7|347.55|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA [1260]|CIGNA PPO [126025]|503.7||||503.7|22.61|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|503.7||||503.7|347.55|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|503.7||||503.7|10.02|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|503.7||||503.7|347.55|382.81|10.02
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]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|503.7||||503.7|0|382.81|10.02
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]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|503.7||||503.7|347.55|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|Self-pay|Self-pay|503.7||||503.7|100.74|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|TML [1980]|TML [198000]|503.7||||503.7|347.55|382.81|10.02
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]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNICARE [2040]|UNICARE [204000]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|503.7||||503.7||382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WEB TPA [2115]|WEB TPA [211500]|503.7||||503.7|347.55|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|503.7||||503.7|0|382.81|10.02
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]|503.7||||503.7|0|382.81|10.02
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WORKER'S COMP [2125]|TML WC [212537]|503.7||||503.7||382.81|10.02
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AARP [1000]|AARP [100000]|549.24||||549.24|6.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA [1015]|AETNA [101529]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMBETTER [2930]|AMBETTER [293000]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|549.24||||549.24|10.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|549.24||||549.24|395.45|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|549.24||||549.24|274.62|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|549.24||||549.24|274.62|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|549.24||||549.24|417.42|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA [1260]|CIGNA PPO [126025]|549.24||||549.24|24.63|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|549.24||||549.24|6.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|549.24||||549.24|10.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|Self-pay|Self-pay|549.24||||549.24|109.85|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|TML [1980]|TML [198000]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|549.24||||549.24|11.23|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|549.24||||549.24|6.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNICARE [2040]|UNICARE [204000]|549.24||||549.24|6.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|549.24||||549.24|6.93|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WEB TPA [2115]|WEB TPA [211500]|549.24||||549.24|378.98|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|549.24||||549.24|0|417.42|6.93
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WORKER'S COMP [2125]|TML WC [212537]|549.24||||549.24|6.93|417.42|6.93
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AARP [1000]|AARP [100000]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA [1015]|AETNA [101529]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMBETTER [2930]|AMBETTER [293000]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|587.88||||587.88|26.6|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|587.88||||587.88|423.27|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|587.88||||587.88|293.94|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|587.88||||587.88|293.94|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|587.88||||587.88|446.79|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA [1260]|CIGNA PPO [126025]|587.88||||587.88|26.41|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|587.88||||587.88|26.6|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|Self-pay|Self-pay|587.88||||587.88|117.58|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|TML [1980]|TML [198000]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNICARE [2040]|UNICARE [204000]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|587.88||||587.88||446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WEB TPA [2115]|WEB TPA [211500]|587.88||||587.88|405.64|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|587.88||||587.88|0|446.79|26.41
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WORKER'S COMP [2125]|TML WC [212537]|587.88||||587.88||446.79|26.41
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AARP [1000]|AARP [100000]|411||||411|8.51|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA [1015]|AETNA [101529]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMBETTER [2930]|AMBETTER [293000]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|411||||411|13.42|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|411||||411|295.92|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|411||||411|205.5|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|411||||411|205.5|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|411||||411|312.36|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA [1260]|CIGNA PPO [126025]|411||||411|30.29|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|411||||411|8.51|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|411||||411|13.42|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|Self-pay|Self-pay|411||||411|82.2|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|TML [1980]|TML [198000]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|411||||411|13.79|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|411||||411|8.51|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNICARE [2040]|UNICARE [204000]|411||||411|8.51|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|411||||411|8.51|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WEB TPA [2115]|WEB TPA [211500]|411||||411|283.59|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|411||||411|0|312.36|8.51
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WORKER'S COMP [2125]|TML WC [212537]|411||||411|8.51|312.36|8.51
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AARP [1000]|AARP [100000]|521.64||||521.64|8.91|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA [1015]|AETNA [101529]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMBETTER [2930]|AMBETTER [293000]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|521.64||||521.64|14.04|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|521.64||||521.64|375.58|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|521.64||||521.64|260.82|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|521.64||||521.64|260.82|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|521.64||||521.64|396.45|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA [1260]|CIGNA PPO [126025]|521.64||||521.64|31.64|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|521.64||||521.64|8.91|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|521.64||||521.64|14.04|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|Self-pay|Self-pay|521.64||||521.64|104.33|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|TML [1980]|TML [198000]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|521.64||||521.64|14.42|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|521.64||||521.64|8.91|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNICARE [2040]|UNICARE [204000]|521.64||||521.64|8.91|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|521.64||||521.64|8.91|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WEB TPA [2115]|WEB TPA [211500]|521.64||||521.64|359.93|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|521.64||||521.64|0|396.45|8.91
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]|521.64||||521.64|0|396.45|8.91
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WORKER'S COMP [2125]|TML WC [212537]|521.64||||521.64|8.91|396.45|8.91
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AARP [1000]|AARP [100000]|571.32||||571.32|7.34|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AETNA [1015]|AETNA [101529]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AMBETTER [2930]|AMBETTER [293000]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|571.32||||571.32|11.57|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|571.32||||571.32|411.35|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|571.32||||571.32|285.66|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|571.32||||571.32|285.66|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|571.32||||571.32|434.2|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA [1260]|CIGNA PPO [126025]|571.32||||571.32|26.08|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|571.32||||571.32|7.34|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|571.32||||571.32|11.57|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|Self-pay|Self-pay|571.32||||571.32|114.26|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|TML [1980]|TML [198000]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|571.32||||571.32|11.89|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|571.32||||571.32|7.34|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UNICARE [2040]|UNICARE [204000]|571.32||||571.32|7.34|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|571.32||||571.32|7.34|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WEB TPA [2115]|WEB TPA [211500]|571.32||||571.32|394.21|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|571.32||||571.32|0|434.2|7.34
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WORKER'S COMP [2125]|TML WC [212537]|571.32||||571.32|7.34|434.2|7.34
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AARP [1000]|AARP [100000]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA [1015]|AETNA [101529]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMBETTER [2930]|AMBETTER [293000]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|189.25||||189.25|6.18|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|189.25||||189.25||143.83|6.18
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]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.25||||189.25|136.26|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.25||||189.25|94.63|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.25||||189.25|94.63|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|189.25||||189.25|143.83|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|189.25||||189.25|130.58|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA [1260]|CIGNA PPO [126025]|189.25||||189.25|13.94|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189.25||||189.25|130.58|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|189.25||||189.25|6.18|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|189.25||||189.25|130.58|143.83|6.18
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]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.25||||189.25|0|143.83|6.18
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]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189.25||||189.25|130.58|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|Self-pay|Self-pay|189.25||||189.25|37.85|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|TML [1980]|TML [198000]|189.25||||189.25|130.58|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNICARE [2040]|UNICARE [204000]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.25||||189.25||143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WEB TPA [2115]|WEB TPA [211500]|189.25||||189.25|130.58|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.25||||189.25|0|143.83|6.18
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]|189.25||||189.25|0|143.83|6.18
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WORKER'S COMP [2125]|TML WC [212537]|189.25||||189.25||143.83|6.18
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AARP [1000]|AARP [100000]|449.88||||449.88|5.69|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA [1015]|AETNA [101529]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMBETTER [2930]|AMBETTER [293000]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|449.88||||449.88|9.72|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449.88||||449.88|323.91|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449.88||||449.88|224.94|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449.88||||449.88|224.94|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|449.88||||449.88|341.91|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA [1260]|CIGNA PPO [126025]|449.88||||449.88|20.19|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|449.88||||449.88|5.69|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|449.88||||449.88|9.72|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|Self-pay|Self-pay|449.88||||449.88|89.98|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|TML [1980]|TML [198000]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449.88||||449.88|9.99|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449.88||||449.88|5.69|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNICARE [2040]|UNICARE [204000]|449.88||||449.88|5.69|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449.88||||449.88|5.69|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WEB TPA [2115]|WEB TPA [211500]|449.88||||449.88|310.42|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449.88||||449.88|0|341.91|5.69
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]|449.88||||449.88|0|341.91|5.69
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WORKER'S COMP [2125]|TML WC [212537]|449.88||||449.88|5.69|341.91|5.69
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AARP [1000]|AARP [100000]|344.25||||344.25|7.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA [1015]|AETNA [101529]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMBETTER [2930]|AMBETTER [293000]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|344.25||||344.25|11.25|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344.25||||344.25|247.86|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344.25||||344.25|172.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344.25||||344.25|172.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|344.25||||344.25|261.63|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA [1260]|CIGNA PPO [126025]|344.25||||344.25|25.35|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|344.25||||344.25|7.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|344.25||||344.25|11.25|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|Self-pay|Self-pay|344.25||||344.25|68.85|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|TML [1980]|TML [198000]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344.25||||344.25|11.56|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344.25||||344.25|7.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNICARE [2040]|UNICARE [204000]|344.25||||344.25|7.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344.25||||344.25|7.13|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WEB TPA [2115]|WEB TPA [211500]|344.25||||344.25|237.53|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344.25||||344.25|0|261.63|7.13
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WORKER'S COMP [2125]|TML WC [212537]|344.25||||344.25|7.13|261.63|7.13
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AARP [1000]|AARP [100000]|277.38||||277.38|3.52|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA [1015]|AETNA [101529]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMBETTER [2930]|AMBETTER [293000]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.38||||277.38|5.55|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.38||||277.38|199.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.38||||277.38|138.69|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.38||||277.38|138.69|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.38||||277.38|210.81|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA [1260]|CIGNA PPO [126025]|277.38||||277.38|12.51|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.38||||277.38|3.52|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.38||||277.38|5.55|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|Self-pay|Self-pay|277.38||||277.38|55.48|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|TML [1980]|TML [198000]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.38||||277.38|5.71|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.38||||277.38|3.52|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNICARE [2040]|UNICARE [204000]|277.38||||277.38|3.52|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.38||||277.38|3.52|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WEB TPA [2115]|WEB TPA [211500]|277.38||||277.38|191.39|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.38||||277.38|0|210.81|3.52
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WORKER'S COMP [2125]|TML WC [212537]|277.38||||277.38|3.52|210.81|3.52
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AARP [1000]|AARP [100000]|478.25||||478.25|4.43|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA [1015]|AETNA [101529]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMBETTER [2930]|AMBETTER [293000]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|478.25||||478.25|7.01|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478.25||||478.25|344.34|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478.25||||478.25|239.13|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478.25||||478.25|239.13|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|478.25||||478.25|363.47|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA [1260]|CIGNA PPO [126025]|478.25||||478.25|15.76|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|478.25||||478.25|4.43|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|478.25||||478.25|7.01|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|Self-pay|Self-pay|478.25||||478.25|95.65|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|TML [1980]|TML [198000]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478.25||||478.25|7.2|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478.25||||478.25|4.43|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNICARE [2040]|UNICARE [204000]|478.25||||478.25|4.43|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478.25||||478.25|4.43|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WEB TPA [2115]|WEB TPA [211500]|478.25||||478.25|329.99|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478.25||||478.25|0|363.47|4.43
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WORKER'S COMP [2125]|TML WC [212537]|478.25||||478.25|4.43|363.47|4.43
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AARP [1000]|AARP [100000]|54||||54|14.83|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AETNA [1015]|AETNA [101529]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AMBETTER [2930]|AMBETTER [293000]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|54||||54|23.37|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|38.88|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|27|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|54||||54|41.04|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA [1260]|CIGNA PPO [126025]|54||||54|52.7|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|54||||54|14.83|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|54||||54|23.37|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|Self-pay|Self-pay|54||||54|10.8|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|TML [1980]|TML [198000]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54|24.01|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54|14.83|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UNICARE [2040]|UNICARE [204000]|54||||54|14.83|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54|14.83|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|WEB TPA [2115]|WEB TPA [211500]|54||||54|37.26|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54|0|52.7|10.8
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]|54||||54|0|52.7|10.8
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|WORKER'S COMP [2125]|TML WC [212537]|54||||54|14.83|52.7|10.8
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AARP [1000]|AARP [100000]|277.38||||277.38|3.52|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AETNA [1015]|AETNA [101529]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AMBETTER [2930]|AMBETTER [293000]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.38||||277.38|7.57|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.38||||277.38|199.71|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.38||||277.38|138.69|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.38||||277.38|138.69|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.38||||277.38|210.81|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA [1260]|CIGNA PPO [126025]|277.38||||277.38|12.51|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.38||||277.38|3.52|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.38||||277.38|7.57|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|Self-pay|Self-pay|277.38||||277.38|55.48|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|TML [1980]|TML [198000]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.38||||277.38|7.78|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.38||||277.38|3.52|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UNICARE [2040]|UNICARE [204000]|277.38||||277.38|3.52|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.38||||277.38|3.52|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|WEB TPA [2115]|WEB TPA [211500]|277.38||||277.38|191.39|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.38||||277.38|0|210.81|3.52
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]|277.38||||277.38|0|210.81|3.52
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|WORKER'S COMP [2125]|TML WC [212537]|277.38||||277.38|3.52|210.81|3.52
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AARP [1000]|AARP [100000]|1433.47||||1433.47|21.5|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA [1015]|AETNA [101529]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMBETTER [2930]|AMBETTER [293000]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1433.47||||1433.47|33.89|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1433.47||||1433.47|1032.1|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1433.47||||1433.47|716.74|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1433.47||||1433.47|716.74|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1433.47||||1433.47|1089.44|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA [1260]|CIGNA PPO [126025]|1433.47||||1433.47|76.39|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1433.47||||1433.47|21.5|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1433.47||||1433.47|33.89|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|Self-pay|Self-pay|1433.47||||1433.47|286.69|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|TML [1980]|TML [198000]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1433.47||||1433.47|34.82|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1433.47||||1433.47|21.5|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNICARE [2040]|UNICARE [204000]|1433.47||||1433.47|21.5|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1433.47||||1433.47|21.5|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WEB TPA [2115]|WEB TPA [211500]|1433.47||||1433.47|989.09|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1433.47||||1433.47|0|1089.44|21.5
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WORKER'S COMP [2125]|TML WC [212537]|1433.47||||1433.47|21.5|1089.44|21.5
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AARP [1000]|AARP [100000]|136.96||||136.96|16.13|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AETNA [1015]|AETNA [101529]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AMBETTER [2930]|AMBETTER [293000]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|136.96||||136.96|25.43|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|136.96||||136.96|26.12|104.09|16.13
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]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.96||||136.96|98.61|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.96||||136.96|68.48|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.96||||136.96|68.48|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|136.96||||136.96|104.09|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|136.96||||136.96|94.5|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA [1260]|CIGNA PPO [126025]|136.96||||136.96|57.33|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|136.96||||136.96|16.13|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136.96||||136.96|94.5|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|136.96||||136.96|25.43|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|136.96||||136.96|94.5|104.09|16.13
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]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.96||||136.96|0|104.09|16.13
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]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136.96||||136.96|94.5|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|Self-pay|Self-pay|136.96||||136.96|27.39|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|TML [1980]|TML [198000]|136.96||||136.96|94.5|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.96||||136.96|26.12|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.96||||136.96|16.13|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UNICARE [2040]|UNICARE [204000]|136.96||||136.96|16.13|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.96||||136.96|16.13|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|WEB TPA [2115]|WEB TPA [211500]|136.96||||136.96|94.5|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.96||||136.96|0|104.09|16.13
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]|136.96||||136.96|0|104.09|16.13
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|WORKER'S COMP [2125]|TML WC [212537]|136.96||||136.96|16.13|104.09|16.13
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AARP [1000]|AARP [100000]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|20.28|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|475.19|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|330|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|330|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|501.59|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|35.12|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|20.28|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|Self-pay|Self-pay|659.99||||659.99|132|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99|0|501.59|20.28
30687278|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF LEGIONELLA PNEUMOPHILIA|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||501.59|20.28
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AARP [1000]|AARP [100000]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AETNA [1015]|AETNA [101529]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AMBETTER [2930]|AMBETTER [293000]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|15.57|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|25.92|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|18|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|27.36|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|35.12|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|15.57|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|Self-pay|Self-pay|36||||36|7.2|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|TML [1980]|TML [198000]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UNICARE [2040]|UNICARE [204000]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36|0|35.12|7.2
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||35.12|7.2
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AARP [1000]|AARP [100000]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AETNA [1015]|AETNA [101529]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AMBETTER [2930]|AMBETTER [293000]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.84||||783.84|20.93|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.84||||783.84|564.36|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.84||||783.84|391.92|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.84||||783.84|391.92|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.84||||783.84|595.72|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA [1260]|CIGNA PPO [126025]|783.84||||783.84|35.12|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.84||||783.84|20.93|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|Self-pay|Self-pay|783.84||||783.84|156.77|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|TML [1980]|TML [198000]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UNICARE [2040]|UNICARE [204000]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.84||||783.84||595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WEB TPA [2115]|WEB TPA [211500]|783.84||||783.84|540.85|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|783.84||||783.84|0|595.72|20.93
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WORKER'S COMP [2125]|TML WC [212537]|783.84||||783.84||595.72|20.93
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AARP [1000]|AARP [100000]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AETNA [1015]|AETNA [101529]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMBETTER [2930]|AMBETTER [293000]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.84||||783.84|15.57|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.84||||783.84|564.36|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.84||||783.84|391.92|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.84||||783.84|391.92|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.84||||783.84|595.72|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|CIGNA [1260]|CIGNA PPO [126025]|783.84||||783.84|35.12|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.84||||783.84|15.57|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|Self-pay|Self-pay|783.84||||783.84|156.77|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|TML [1980]|TML [198000]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UNICARE [2040]|UNICARE [204000]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.84||||783.84||595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WEB TPA [2115]|WEB TPA [211500]|783.84||||783.84|540.85|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|783.84||||783.84|0|595.72|15.57
30687300|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT POLYVALENT IF|1|WORKER'S COMP [2125]|TML WC [212537]|783.84||||783.84||595.72|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AARP [1000]|AARP [100000]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AETNA [1015]|AETNA [101529]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AMBETTER [2930]|AMBETTER [293000]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|592.72||||592.72|15.57|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|592.72||||592.72|426.76|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|592.72||||592.72|296.36|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|592.72||||592.72|296.36|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|592.72||||592.72|450.47|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA [1260]|CIGNA PPO [126025]|592.72||||592.72|35.12|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|592.72||||592.72|15.57|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|Self-pay|Self-pay|592.72||||592.72|118.54|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|TML [1980]|TML [198000]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UNICARE [2040]|UNICARE [204000]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|592.72||||592.72||450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WEB TPA [2115]|WEB TPA [211500]|592.72||||592.72|408.98|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|592.72||||592.72|0|450.47|15.57
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WORKER'S COMP [2125]|TML WC [212537]|592.72||||592.72||450.47|15.57
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AARP [1000]|AARP [100000]|573.9||||573.9|9.89|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AETNA [1015]|AETNA [101529]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AMBETTER [2930]|AMBETTER [293000]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|573.9||||573.9|15.57|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|573.9||||573.9|413.21|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|573.9||||573.9|286.95|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|573.9||||573.9|286.95|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|573.9||||573.9|436.16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|CIGNA [1260]|CIGNA PPO [126025]|573.9||||573.9|35.12|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|573.9||||573.9|9.89|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|573.9||||573.9|15.57|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|Self-pay|Self-pay|573.9||||573.9|114.78|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|TML [1980]|TML [198000]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|573.9||||573.9|16|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|573.9||||573.9|9.89|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|UNICARE [2040]|UNICARE [204000]|573.9||||573.9|9.89|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|573.9||||573.9|9.89|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|WEB TPA [2115]|WEB TPA [211500]|573.9||||573.9|395.99|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|573.9||||573.9|0|436.16|9.89
30687324|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG C DIFFICILE TOXIN|1|WORKER'S COMP [2125]|TML WC [212537]|573.9||||573.9|9.89|436.16|9.89
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AARP [1000]|AARP [100000]|741.06||||741.06|8.52|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA [1015]|AETNA [101529]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMBETTER [2930]|AMBETTER [293000]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|741.06||||741.06|13.43|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|741.06||||741.06|13.8|563.21|8.52
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]|741.06||||741.06|0|563.21|8.52
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]|741.06||||741.06|533.56|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|741.06||||741.06|370.53|563.21|8.52
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]|741.06||||741.06|370.53|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|741.06||||741.06|563.21|563.21|8.52
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]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|741.06||||741.06|511.33|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA [1260]|CIGNA PPO [126025]|741.06||||741.06|30.29|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|741.06||||741.06|8.52|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|741.06||||741.06|511.33|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|741.06||||741.06|13.43|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|741.06||||741.06|511.33|563.21|8.52
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]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|741.06||||741.06|0|563.21|8.52
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]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|741.06||||741.06|511.33|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|Self-pay|Self-pay|741.06||||741.06|148.21|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|TML [1980]|TML [198000]|741.06||||741.06|511.33|563.21|8.52
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]|741.06||||741.06|13.8|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|741.06||||741.06|8.52|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNICARE [2040]|UNICARE [204000]|741.06||||741.06|8.52|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|741.06||||741.06|8.52|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WEB TPA [2115]|WEB TPA [211500]|741.06||||741.06|511.33|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|741.06||||741.06|0|563.21|8.52
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]|741.06||||741.06|0|563.21|8.52
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WORKER'S COMP [2125]|TML WC [212537]|741.06||||741.06|8.52|563.21|8.52
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AARP [1000]|AARP [100000]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA [1015]|AETNA [101529]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMBETTER [2930]|AMBETTER [293000]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.99||||659.99|17.23|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|659.99||||659.99|475.19|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|659.99||||659.99|330|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|659.99||||659.99|330|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.99||||659.99|501.59|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA [1260]|CIGNA PPO [126025]|659.99||||659.99|35.12|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.99||||659.99|17.23|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|Self-pay|Self-pay|659.99||||659.99|132|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|TML [1980]|TML [198000]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNICARE [2040]|UNICARE [204000]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.99||||659.99||501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WEB TPA [2115]|WEB TPA [211500]|659.99||||659.99|455.39|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|659.99||||659.99|0|501.59|17.23
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WORKER'S COMP [2125]|TML WC [212537]|659.99||||659.99||501.59|17.23
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AARP [1000]|AARP [100000]|573.9||||573.9|9.89|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA [1015]|AETNA [101529]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMBETTER [2930]|AMBETTER [293000]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|573.9||||573.9|15.57|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|573.9||||573.9|16|436.16|9.89
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]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|573.9||||573.9|413.21|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|573.9||||573.9|286.95|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|573.9||||573.9|286.95|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|573.9||||573.9|436.16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|573.9||||573.9|395.99|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA [1260]|CIGNA PPO [126025]|573.9||||573.9|35.12|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|573.9||||573.9|9.89|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|573.9||||573.9|395.99|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|573.9||||573.9|15.57|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|573.9||||573.9|395.99|436.16|9.89
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]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|573.9||||573.9|0|436.16|9.89
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]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|573.9||||573.9|395.99|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|Self-pay|Self-pay|573.9||||573.9|114.78|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|TML [1980]|TML [198000]|573.9||||573.9|395.99|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|573.9||||573.9|16|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|573.9||||573.9|9.89|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNICARE [2040]|UNICARE [204000]|573.9||||573.9|9.89|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|573.9||||573.9|9.89|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WEB TPA [2115]|WEB TPA [211500]|573.9||||573.9|395.99|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|573.9||||573.9|0|436.16|9.89
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]|573.9||||573.9|0|436.16|9.89
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WORKER'S COMP [2125]|TML WC [212537]|573.9||||573.9|9.89|436.16|9.89
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AARP [1000]|AARP [100000]|126||||126|28.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA [1015]|AETNA [101529]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMBETTER [2930]|AMBETTER [293000]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126||||126|48.45|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126||||126|49.78|102.84|25.2
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]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|90.72|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|63|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126||||126|95.76|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA [1260]|CIGNA PPO [126025]|126||||126|102.84|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126||||126|28.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126||||126|48.45|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126||||126|86.94|102.84|25.2
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]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|0|102.84|25.2
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]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|Self-pay|Self-pay|126||||126|25.2|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|TML [1980]|TML [198000]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126|49.78|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126|28.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNICARE [2040]|UNICARE [204000]|126||||126|28.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126|28.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WEB TPA [2115]|WEB TPA [211500]|126||||126|86.94|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126|0|102.84|25.2
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]|126||||126|0|102.84|25.2
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WORKER'S COMP [2125]|TML WC [212537]|126||||126|28.94|102.84|25.2
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AARP [1000]|AARP [100000]|1130.75||||1130.75|35.33|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA [1015]|AETNA [101529]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMBETTER [2930]|AMBETTER [293000]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.75||||1130.75|55.69|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.75||||1130.75|814.14|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.75||||1130.75|565.38|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.75||||1130.75|565.38|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.75||||1130.75|859.37|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA [1260]|CIGNA PPO [126025]|1130.75||||1130.75|125.55|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.75||||1130.75|35.33|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.75||||1130.75|55.69|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|Self-pay|Self-pay|1130.75||||1130.75|226.15|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|TML [1980]|TML [198000]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.75||||1130.75|57.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.75||||1130.75|35.33|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNICARE [2040]|UNICARE [204000]|1130.75||||1130.75|35.33|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.75||||1130.75|35.33|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WEB TPA [2115]|WEB TPA [211500]|1130.75||||1130.75|780.22|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.75||||1130.75|0|859.37|35.33
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]|1130.75||||1130.75|0|859.37|35.33
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WORKER'S COMP [2125]|TML WC [212537]|1130.75||||1130.75|35.33|859.37|35.33
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AARP [1000]|AARP [100000]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA [1015]|AETNA [101529]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMBETTER [2930]|AMBETTER [293000]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|647.22||||647.22|124.54|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|647.22||||647.22|466|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|647.22||||647.22|323.61|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|647.22||||647.22|323.61|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|647.22||||647.22|491.89|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA [1260]|CIGNA PPO [126025]|647.22||||647.22|249.41|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|647.22||||647.22|124.54|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|Self-pay|Self-pay|647.22||||647.22|129.44|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|TML [1980]|TML [198000]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNICARE [2040]|UNICARE [204000]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|647.22||||647.22||491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WEB TPA [2115]|WEB TPA [211500]|647.22||||647.22|446.58|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|647.22||||647.22|0|491.89|124.54
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WORKER'S COMP [2125]|TML WC [212537]|647.22||||647.22||491.89|124.54
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AARP [1000]|AARP [100000]|1560.43||||1560.43|35.33|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AETNA [1015]|AETNA [101529]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AMBETTER [2930]|AMBETTER [293000]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1560.43||||1560.43|55.69|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1560.43||||1560.43|1123.51|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1560.43||||1560.43|780.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1560.43||||1560.43|780.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1560.43||||1560.43|1185.93|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA [1260]|CIGNA PPO [126025]|1560.43||||1560.43|125.55|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1560.43||||1560.43|35.33|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1560.43||||1560.43|55.69|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|Self-pay|Self-pay|1560.43||||1560.43|312.09|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|TML [1980]|TML [198000]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1560.43||||1560.43|57.22|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1560.43||||1560.43|35.33|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UNICARE [2040]|UNICARE [204000]|1560.43||||1560.43|35.33|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1560.43||||1560.43|35.33|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|WEB TPA [2115]|WEB TPA [211500]|1560.43||||1560.43|1076.7|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1560.43||||1560.43|0|1185.93|35.33
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]|1560.43||||1560.43|0|1185.93|35.33
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|WORKER'S COMP [2125]|TML WC [212537]|1560.43||||1560.43|35.33|1185.93|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AARP [1000]|AARP [100000]|1130.75||||1130.75|35.33|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA [1015]|AETNA [101529]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMBETTER [2930]|AMBETTER [293000]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1130.75||||1130.75|55.69|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1130.75||||1130.75|57.22|859.37|35.33
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]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1130.75||||1130.75|814.14|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1130.75||||1130.75|565.38|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1130.75||||1130.75|565.38|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1130.75||||1130.75|859.37|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1130.75||||1130.75|780.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA [1260]|CIGNA PPO [126025]|1130.75||||1130.75|125.55|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1130.75||||1130.75|35.33|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1130.75||||1130.75|780.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1130.75||||1130.75|55.69|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1130.75||||1130.75|780.22|859.37|35.33
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]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1130.75||||1130.75|0|859.37|35.33
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]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1130.75||||1130.75|780.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|Self-pay|Self-pay|1130.75||||1130.75|226.15|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|TML [1980]|TML [198000]|1130.75||||1130.75|780.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1130.75||||1130.75|57.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1130.75||||1130.75|35.33|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNICARE [2040]|UNICARE [204000]|1130.75||||1130.75|35.33|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1130.75||||1130.75|35.33|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WEB TPA [2115]|WEB TPA [211500]|1130.75||||1130.75|780.22|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1130.75||||1130.75|0|859.37|35.33
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]|1130.75||||1130.75|0|859.37|35.33
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WORKER'S COMP [2125]|TML WC [212537]|1130.75||||1130.75|35.33|859.37|35.33
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AARP [1000]|AARP [100000]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA [1015]|AETNA [101529]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMBETTER [2930]|AMBETTER [293000]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1887.49||||1887.49|45.62|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1887.49||||1887.49||1434.49|45.62
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]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1887.49||||1887.49|1358.99|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1887.49||||1887.49|943.75|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1887.49||||1887.49|943.75|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1887.49||||1887.49|1434.49|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1887.49||||1887.49|1302.37|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA [1260]|CIGNA PPO [126025]|1887.49||||1887.49|102.84|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1887.49||||1887.49|1302.37|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1887.49||||1887.49|45.62|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1887.49||||1887.49|1302.37|1434.49|45.62
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]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1887.49||||1887.49|0|1434.49|45.62
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]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1887.49||||1887.49|1302.37|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|Self-pay|Self-pay|1887.49||||1887.49|377.5|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|TML [1980]|TML [198000]|1887.49||||1887.49|1302.37|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNICARE [2040]|UNICARE [204000]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1887.49||||1887.49||1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WEB TPA [2115]|WEB TPA [211500]|1887.49||||1887.49|1302.37|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1887.49||||1887.49|0|1434.49|45.62
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]|1887.49||||1887.49|0|1434.49|45.62
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WORKER'S COMP [2125]|TML WC [212537]|1887.49||||1887.49||1434.49|45.62
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AARP [1000]|AARP [100000]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AETNA [1015]|AETNA [101529]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AMBETTER [2930]|AMBETTER [293000]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|559.32||||559.32|54.18|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|559.32||||559.32|402.71|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|559.32||||559.32|279.66|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|559.32||||559.32|279.66|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|559.32||||559.32|425.08|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA [1260]|CIGNA PPO [126025]|559.32||||559.32|102.84|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|559.32||||559.32|54.18|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|Self-pay|Self-pay|559.32||||559.32|111.86|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|TML [1980]|TML [198000]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UNICARE [2040]|UNICARE [204000]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|559.32||||559.32||425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WEB TPA [2115]|WEB TPA [211500]|559.32||||559.32|385.93|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|559.32||||559.32|0|425.08|54.18
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WORKER'S COMP [2125]|TML WC [212537]|559.32||||559.32||425.08|54.18
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AARP [1000]|AARP [100000]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AETNA [1015]|AETNA [101529]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AMBETTER [2930]|AMBETTER [293000]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|358.84||||358.84|45.62|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|358.84||||358.84|258.36|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|358.84||||358.84|179.42|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|358.84||||358.84|179.42|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|358.84||||358.84|272.72|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|CIGNA [1260]|CIGNA PPO [126025]|358.84||||358.84|102.84|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|358.84||||358.84|45.62|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|Self-pay|Self-pay|358.84||||358.84|71.77|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|TML [1980]|TML [198000]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|UNICARE [2040]|UNICARE [204000]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|358.84||||358.84||272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|WEB TPA [2115]|WEB TPA [211500]|358.84||||358.84|247.6|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|358.84||||358.84|0|272.72|45.62
30687561|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIA AMP NA PROBE|1|WORKER'S COMP [2125]|TML WC [212537]|358.84||||358.84||272.72|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AARP [1000]|AARP [100000]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA [1015]|AETNA [101529]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMBETTER [2930]|AMBETTER [293000]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|287.04||||287.04|45.62|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|287.04||||287.04||218.15|45.62
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]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|287.04||||287.04|206.67|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|287.04||||287.04|143.52|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|287.04||||287.04|143.52|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|287.04||||287.04|218.15|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|287.04||||287.04|198.06|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA [1260]|CIGNA PPO [126025]|287.04||||287.04|102.84|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|287.04||||287.04|198.06|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|287.04||||287.04|45.62|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|287.04||||287.04|198.06|218.15|45.62
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]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|287.04||||287.04|0|218.15|45.62
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]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|287.04||||287.04|198.06|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|Self-pay|Self-pay|287.04||||287.04|57.41|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|TML [1980]|TML [198000]|287.04||||287.04|198.06|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNICARE [2040]|UNICARE [204000]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|287.04||||287.04||218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WEB TPA [2115]|WEB TPA [211500]|287.04||||287.04|198.06|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|287.04||||287.04|0|218.15|45.62
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]|287.04||||287.04|0|218.15|45.62
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WORKER'S COMP [2125]|TML WC [212537]|287.04||||287.04||218.15|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AARP [1000]|AARP [100000]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA [1015]|AETNA [101529]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMBETTER [2930]|AMBETTER [293000]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1367.75||||1367.75|45.62|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1367.75||||1367.75|984.78|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1367.75||||1367.75|683.88|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1367.75||||1367.75|683.88|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1367.75||||1367.75|1039.49|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA [1260]|CIGNA PPO [126025]|1367.75||||1367.75|102.84|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1367.75||||1367.75|45.62|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|Self-pay|Self-pay|1367.75||||1367.75|273.55|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|TML [1980]|TML [198000]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNICARE [2040]|UNICARE [204000]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1367.75||||1367.75||1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WEB TPA [2115]|WEB TPA [211500]|1367.75||||1367.75|943.75|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1367.75||||1367.75|0|1039.49|45.62
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]|1367.75||||1367.75|0|1039.49|45.62
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WORKER'S COMP [2125]|TML WC [212537]|1367.75||||1367.75||1039.49|45.62
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AARP [1000]|AARP [100000]|559.32||||559.32|35.33|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA [1015]|AETNA [101529]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMBETTER [2930]|AMBETTER [293000]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|559.32||||559.32|55.69|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|559.32||||559.32|57.22|425.08|35.33
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]|559.32||||559.32|0|425.08|35.33
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]|559.32||||559.32|402.71|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|559.32||||559.32|279.66|425.08|35.33
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]|559.32||||559.32|279.66|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|559.32||||559.32|425.08|425.08|35.33
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]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|559.32||||559.32|385.93|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA [1260]|CIGNA PPO [126025]|559.32||||559.32|125.55|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|559.32||||559.32|35.33|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|559.32||||559.32|385.93|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|559.32||||559.32|55.69|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|559.32||||559.32|385.93|425.08|35.33
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]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|559.32||||559.32|0|425.08|35.33
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]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|559.32||||559.32|385.93|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|Self-pay|Self-pay|559.32||||559.32|111.86|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|TML [1980]|TML [198000]|559.32||||559.32|385.93|425.08|35.33
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]|559.32||||559.32|57.22|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|559.32||||559.32|35.33|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNICARE [2040]|UNICARE [204000]|559.32||||559.32|35.33|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|559.32||||559.32|35.33|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WEB TPA [2115]|WEB TPA [211500]|559.32||||559.32|385.93|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|559.32||||559.32|0|425.08|35.33
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]|559.32||||559.32|0|425.08|35.33
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WORKER'S COMP [2125]|TML WC [212537]|559.32||||559.32|35.33|425.08|35.33
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AARP [1000]|AARP [100000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA [1015]|AETNA [101529]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMBETTER [2930]|AMBETTER [293000]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36||||36|21.52|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|25.92|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|18|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36||||36|27.36|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA [1260]|CIGNA PPO [126025]|36||||36|35.12|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36||||36|21.52|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|Self-pay|Self-pay|36||||36|7.2|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|TML [1980]|TML [198000]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNICARE [2040]|UNICARE [204000]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WEB TPA [2115]|WEB TPA [211500]|36||||36|24.84|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|0|35.12|7.2
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]|36||||36|0|35.12|7.2
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WORKER'S COMP [2125]|TML WC [212537]|36||||36||35.12|7.2
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AARP [1000]|AARP [100000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA [1015]|AETNA [101529]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMBETTER [2930]|AMBETTER [293000]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37||||37|21.49|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|26.64|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|18.5|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|18.5|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37||||37|28.12|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA [1260]|CIGNA PPO [126025]|37||||37|35.12|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37||||37|21.49|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|Self-pay|Self-pay|37||||37|7.4|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|TML [1980]|TML [198000]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNICARE [2040]|UNICARE [204000]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37||35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WEB TPA [2115]|WEB TPA [211500]|37||||37|25.53|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37|0|35.12|7.4
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]|37||||37|0|35.12|7.4
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WORKER'S COMP [2125]|TML WC [212537]|37||||37||35.12|7.4
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AARP [1000]|AARP [100000]|659.66||||659.66||501.34|20.89
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]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AETNA [1015]|AETNA [101529]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMBETTER [2930]|AMBETTER [293000]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|659.66||||659.66|20.89|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|659.66||||659.66||501.34|20.89
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]|659.66||||659.66|0|501.34|20.89
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]|659.66||||659.66|474.96|501.34|20.89
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]|659.66||||659.66|329.83|501.34|20.89
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]|659.66||||659.66|329.83|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|659.66||||659.66|501.34|501.34|20.89
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]|659.66||||659.66||501.34|20.89
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]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|659.66||||659.66|455.17|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA [1260]|CIGNA PPO [126025]|659.66||||659.66|35.12|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|659.66||||659.66|455.17|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|659.66||||659.66|20.89|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|659.66||||659.66|455.17|501.34|20.89
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]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|659.66||||659.66|0|501.34|20.89
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]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|659.66||||659.66|455.17|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|Self-pay|Self-pay|659.66||||659.66|131.93|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|TML [1980]|TML [198000]|659.66||||659.66|455.17|501.34|20.89
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]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNICARE [2040]|UNICARE [204000]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|659.66||||659.66||501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WEB TPA [2115]|WEB TPA [211500]|659.66||||659.66|455.17|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|659.66||||659.66|0|501.34|20.89
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]|659.66||||659.66|0|501.34|20.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WORKER'S COMP [2125]|TML WC [212537]|659.66||||659.66||501.34|20.89
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AARP [1000]|AARP [100000]|1958.5||||1958.5|212.33|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AETNA [1015]|AETNA [101529]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AMBETTER [2930]|AMBETTER [293000]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1958.5||||1958.5|334.69|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1958.5||||1958.5|1410.12|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1958.5||||1958.5|979.25|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1958.5||||1958.5|979.25|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1958.5||||1958.5|1488.46|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA [1260]|CIGNA PPO [126025]|1958.5||||1958.5|754.51|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1958.5||||1958.5|212.33|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1958.5||||1958.5|334.69|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|Self-pay|Self-pay|1958.5||||1958.5|391.7|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|TML [1980]|TML [198000]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1958.5||||1958.5|343.85|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1958.5||||1958.5|212.33|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UNICARE [2040]|UNICARE [204000]|1958.5||||1958.5|212.33|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1958.5||||1958.5|212.33|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WEB TPA [2115]|WEB TPA [211500]|1958.5||||1958.5|1351.37|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1958.5||||1958.5|0|1488.46|212.33
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WORKER'S COMP [2125]|TML WC [212537]|1958.5||||1958.5|212.33|1488.46|212.33
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]|44.82||||44.82||34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMBETTER [2930]|AMBETTER [293000]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.82||||44.82|22.41|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|32.27|34.06|8.96
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]|44.82||||44.82|22.41|34.06|8.96
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]|44.82||||44.82|22.41|34.06|8.96
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 TRADITIONAL OF TEXAS [115503]|44.82||||44.82|34.06|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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 - GREAT WEST [126009]|44.82||||44.82|30.93|34.06|8.96
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 PPO [126025]|44.82||||44.82|17.93|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.82||||44.82||34.06|8.96
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]|44.82||||44.82|30.93|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.82||||44.82|22.41|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.82||||44.82|30.93|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82|30.93|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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|44.82||||44.82|8.96|34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|TML [1980]|TML [198000]|44.82||||44.82|30.93|34.06|8.96
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]|44.82||||44.82|17.44|34.06|8.96
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]|44.82||||44.82||34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNICARE [2040]|UNICARE [204000]|44.82||||44.82||34.06|8.96
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]|44.82||||44.82||34.06|8.96
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WEB TPA [2115]|WEB TPA [211500]|44.82||||44.82|30.93|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|44.82||||44.82|0|34.06|8.96
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]|TML WC [212537]|44.82||||44.82||34.06|8.96
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AARP [1000]|AARP [100000]|139.38||||139.38|2.61|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA [1015]|AETNA [101529]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMBETTER [2930]|AMBETTER [293000]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139.38||||139.38|4.12|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.38||||139.38|100.35|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.38||||139.38|69.69|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.38||||139.38|69.69|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139.38||||139.38|105.93|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA [1260]|CIGNA PPO [126025]|139.38||||139.38|9.3|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139.38||||139.38|2.61|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139.38||||139.38|4.12|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|Self-pay|Self-pay|139.38||||139.38|27.88|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|TML [1980]|TML [198000]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.38||||139.38|4.23|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.38||||139.38|2.61|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNICARE [2040]|UNICARE [204000]|139.38||||139.38|2.61|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.38||||139.38|2.61|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WEB TPA [2115]|WEB TPA [211500]|139.38||||139.38|96.17|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.38||||139.38|0|105.93|2.61
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WORKER'S COMP [2125]|TML WC [212537]|139.38||||139.38|2.61|105.93|2.61
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AARP [1000]|AARP [100000]|121.44||||121.44|2.11|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AETNA [1015]|AETNA [101529]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AMBETTER [2930]|AMBETTER [293000]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|121.44||||121.44|4.52|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|121.44||||121.44|87.44|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|121.44||||121.44|60.72|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|121.44||||121.44|60.72|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|121.44||||121.44|92.29|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA [1260]|CIGNA PPO [126025]|121.44||||121.44|7.48|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|121.44||||121.44|2.11|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|121.44||||121.44|4.52|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|Self-pay|Self-pay|121.44||||121.44|24.29|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|TML [1980]|TML [198000]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|121.44||||121.44|4.64|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|121.44||||121.44|2.11|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UNICARE [2040]|UNICARE [204000]|121.44||||121.44|2.11|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|121.44||||121.44|2.11|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WEB TPA [2115]|WEB TPA [211500]|121.44||||121.44|83.79|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|121.44||||121.44|0|92.29|2.11
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WORKER'S COMP [2125]|TML WC [212537]|121.44||||121.44|2.11|92.29|2.11
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AARP [1000]|AARP [100000]|126.25||||126.25|1.85|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA [1015]|AETNA [101529]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMBETTER [2930]|AMBETTER [293000]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|126.25||||126.25|2.93|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126.25||||126.25|90.9|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126.25||||126.25|63.13|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126.25||||126.25|63.13|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|126.25||||126.25|95.95|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA [1260]|CIGNA PPO [126025]|126.25||||126.25|6.59|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|126.25||||126.25|1.85|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|126.25||||126.25|2.93|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|Self-pay|Self-pay|126.25||||126.25|25.25|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|TML [1980]|TML [198000]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126.25||||126.25|3.01|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126.25||||126.25|1.85|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNICARE [2040]|UNICARE [204000]|126.25||||126.25|1.85|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126.25||||126.25|1.85|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WEB TPA [2115]|WEB TPA [211500]|126.25||||126.25|87.11|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126.25||||126.25|0|95.95|1.85
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WORKER'S COMP [2125]|TML WC [212537]|126.25||||126.25|1.85|95.95|1.85
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AARP [1000]|AARP [100000]|165.6||||165.6|2.51|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA [1015]|AETNA [101529]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMBETTER [2930]|AMBETTER [293000]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|165.6||||165.6|3.97|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165.6||||165.6|119.23|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165.6||||165.6|82.8|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165.6||||165.6|82.8|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|165.6||||165.6|125.86|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|165.6||||165.6|8.94|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|165.6||||165.6|2.51|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|165.6||||165.6|3.97|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|Self-pay|Self-pay|165.6||||165.6|33.12|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|TML [1980]|TML [198000]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165.6||||165.6|4.07|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165.6||||165.6|2.51|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNICARE [2040]|UNICARE [204000]|165.6||||165.6|2.51|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165.6||||165.6|2.51|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WEB TPA [2115]|WEB TPA [211500]|165.6||||165.6|114.26|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165.6||||165.6|0|125.86|2.51
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|165.6||||165.6|2.51|125.86|2.51
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AARP [1000]|AARP [100000]|343.62||||343.62|5.22|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA [1015]|AETNA [101529]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMBETTER [2930]|AMBETTER [293000]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|343.62||||343.62|11.19|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.62||||343.62|247.41|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.62||||343.62|171.81|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.62||||343.62|171.81|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|343.62||||343.62|261.15|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA [1260]|CIGNA PPO [126025]|343.62||||343.62|18.54|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|343.62||||343.62|5.22|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|343.62||||343.62|11.19|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|Self-pay|Self-pay|343.62||||343.62|68.72|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|TML [1980]|TML [198000]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.62||||343.62|11.5|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.62||||343.62|5.22|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNICARE [2040]|UNICARE [204000]|343.62||||343.62|5.22|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.62||||343.62|5.22|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WEB TPA [2115]|WEB TPA [211500]|343.62||||343.62|237.1|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.62||||343.62|0|261.15|5.22
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WORKER'S COMP [2125]|TML WC [212537]|343.62||||343.62|5.22|261.15|5.22
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AARP [1000]|AARP [100000]|190.08||||190.08||144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AETNA [1015]|AETNA [101529]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AMBETTER [2930]|AMBETTER [293000]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190.08||||190.08|73.98|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|190.08||||190.08|95.04|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|190.08||||190.08|73.98|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
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]|190.08||||190.08|136.86|144.46|38.02
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]|190.08||||190.08|95.04|144.46|38.02
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]|190.08||||190.08|95.04|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|190.08||||190.08|144.46|144.46|38.02
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]|190.08||||190.08|73.98|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|190.08||||190.08|131.16|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|CIGNA [1260]|CIGNA PPO [126025]|190.08||||190.08|76.03|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|190.08||||190.08||144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|190.08||||190.08|131.16|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|190.08||||190.08|95.04|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|190.08||||190.08|131.16|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190.08||||190.08|0|144.46|38.02
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]|190.08||||190.08|73.98|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190.08||||190.08|0|144.46|38.02
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]|190.08||||190.08|73.98|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|190.08||||190.08|131.16|144.46|38.02
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]|190.08||||190.08|73.98|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|Self-pay|Self-pay|190.08||||190.08|38.02|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|TML [1980]|TML [198000]|190.08||||190.08|131.16|144.46|38.02
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]|190.08||||190.08|73.98|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190.08||||190.08||144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UNICARE [2040]|UNICARE [204000]|190.08||||190.08||144.46|38.02
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]|190.08||||190.08||144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|WEB TPA [2115]|WEB TPA [211500]|190.08||||190.08|131.16|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
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]|190.08||||190.08|0|144.46|38.02
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|WORKER'S COMP [2125]|TML WC [212537]|190.08||||190.08||144.46|38.02
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|10.82||||10.82||8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.82||||10.82|4.21|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.82||||10.82|5.41|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.82||||10.82|4.21|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|7.79|8.22|2.16
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]|10.82||||10.82|5.41|8.22|2.16
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]|10.82||||10.82|5.41|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.82||||10.82|8.22|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.82||||10.82|7.47|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|10.82||||10.82|4.33|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.82||||10.82||8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|10.82||||10.82|7.47|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.82||||10.82|5.41|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.82||||10.82|7.47|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|10.82||||10.82|7.47|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|Self-pay|Self-pay|10.82||||10.82|2.16|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|10.82||||10.82|7.47|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.82||||10.82||8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|10.82||||10.82||8.22|2.16
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]|10.82||||10.82||8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|10.82||||10.82|7.47|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|10.82||||10.82||8.22|2.16
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.15||||4.15||3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.15||||4.15|2.08|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.15||||4.15|1.62|3.15|0.83
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]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.15||||4.15|2.99|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.15||||4.15|2.08|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.15||||4.15|2.08|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.15||||4.15|3.15|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.15||||4.15|2.86|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.15||||4.15|1.66|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.15||||4.15||3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.15||||4.15|2.86|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.15||||4.15|2.08|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.15||||4.15|2.86|3.15|0.83
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]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.15||||4.15|0|3.15|0.83
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]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.15||||4.15|2.86|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.15||||4.15|0.83|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.15||||4.15|2.86|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.15||||4.15|1.62|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.15||||4.15||3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.15||||4.15||3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.15||||4.15||3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.15||||4.15|2.86|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.15||||4.15|0|3.15|0.83
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]|4.15||||4.15|0|3.15|0.83
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.15||||4.15||3.15|0.83
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AARP [1000]|AARP [100000]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA [1015]|AETNA [101529]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMBETTER [2930]|AMBETTER [293000]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|159.75||||159.75|85.4|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|159.75||||159.75|115.02|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|159.75||||159.75|79.88|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|159.75||||159.75|79.88|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|159.75||||159.75|121.41|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA [1260]|CIGNA PPO [126025]|159.75||||159.75|144.22|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|159.75||||159.75|85.4|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|Self-pay|Self-pay|159.75||||159.75|31.95|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|TML [1980]|TML [198000]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNICARE [2040]|UNICARE [204000]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|159.75||||159.75||144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WEB TPA [2115]|WEB TPA [211500]|159.75||||159.75|110.23|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|159.75||||159.75|0|144.22|31.95
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WORKER'S COMP [2125]|TML WC [212537]|159.75||||159.75||144.22|31.95
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AARP [1000]|AARP [100000]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA [1015]|AETNA [101529]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMBETTER [2930]|AMBETTER [293000]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1591||||1591|95.38|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1591||||1591|1145.52|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1591||||1591|795.5|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1591||||1591|795.5|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1591||||1591|1209.16|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA [1260]|CIGNA PPO [126025]|1591||||1591|179.1|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1591||||1591|95.38|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|Self-pay|Self-pay|1591||||1591|318.2|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|TML [1980]|TML [198000]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNICARE [2040]|UNICARE [204000]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1591||||1591||1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WEB TPA [2115]|WEB TPA [211500]|1591||||1591|1097.79|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1591||||1591|0|1209.16|95.38
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WORKER'S COMP [2125]|TML WC [212537]|1591||||1591||1209.16|95.38
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AARP [1000]|AARP [100000]|836||||836|53.5|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA [1015]|AETNA [101529]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMBETTER [2930]|AMBETTER [293000]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|836||||836|84.97|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|836||||836|601.92|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|836||||836|418|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|836||||836|418|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|836||||836|635.36|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA [1260]|CIGNA PPO [126025]|836||||836|191.58|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|836||||836|53.5|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|836||||836|84.97|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|Self-pay|Self-pay|836||||836|167.2|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|TML [1980]|TML [198000]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|836||||836|87.29|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|836||||836|53.5|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNICARE [2040]|UNICARE [204000]|836||||836|53.5|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|836||||836|53.5|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WEB TPA [2115]|WEB TPA [211500]|836||||836|576.84|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|836||||836|0|635.36|53.5
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WORKER'S COMP [2125]|TML WC [212537]|836||||836|53.5|635.36|53.5
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AARP [1000]|AARP [100000]|1983.75||||1983.75|75.04|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AETNA [1015]|AETNA [101529]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AMBETTER [2930]|AMBETTER [293000]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1983.75||||1983.75|119.16|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1983.75||||1983.75|1428.3|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1983.75||||1983.75|991.88|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1983.75||||1983.75|991.88|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1983.75||||1983.75|1507.65|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA [1260]|CIGNA PPO [126025]|1983.75||||1983.75|268.67|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1983.75||||1983.75|75.04|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1983.75||||1983.75|119.16|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|Self-pay|Self-pay|1983.75||||1983.75|396.75|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|TML [1980]|TML [198000]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1983.75||||1983.75|122.41|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1983.75||||1983.75|75.04|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UNICARE [2040]|UNICARE [204000]|1983.75||||1983.75|75.04|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1983.75||||1983.75|75.04|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|WEB TPA [2115]|WEB TPA [211500]|1983.75||||1983.75|1368.79|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1983.75||||1983.75|0|1507.65|75.04
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]|1983.75||||1983.75|0|1507.65|75.04
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|WORKER'S COMP [2125]|TML WC [212537]|1983.75||||1983.75|75.04|1507.65|75.04
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|2024.22||||2024.22||1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2024.22||||2024.22|1012.11|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2024.22||||2024.22|1457.44|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2024.22||||2024.22|1012.11|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2024.22||||2024.22|1012.11|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2024.22||||2024.22|1538.41|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2024.22||||2024.22|809.69|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2024.22||||2024.22||1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2024.22||||2024.22|1012.11|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|Self-pay|Self-pay|2024.22||||2024.22|404.84|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|TML [1980]|TML [198000]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2024.22||||2024.22|787.83|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2024.22||||2024.22||1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|2024.22||||2024.22||1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2024.22||||2024.22||1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|2024.22||||2024.22|1396.71|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2024.22||||2024.22|0|1538.41|404.84
31158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.15 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2024.22||||2024.22||1538.41|404.84
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AARP [1000]|AARP [100000]|450.5||||450.5||342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|43.99|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|324.36|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|225.25|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|225.25|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|342.38|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|100.13|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5||342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|43.99|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|Self-pay|Self-pay|450.5||||450.5|90.1|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|175.33|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5||342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5||342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5||342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5|0|342.38|43.99
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5||342.38|43.99
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AARP [1000]|AARP [100000]|183||||183|14.06|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA [1015]|AETNA [101529]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMBETTER [2930]|AMBETTER [293000]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|183||||183|64.69|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|131.76|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|91.5|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|91.5|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|183||||183|139.08|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA [1260]|CIGNA PPO [126025]|183||||183|93.21|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|183||||183|14.06|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|183||||183|64.69|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|Self-pay|Self-pay|183||||183|36.6|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|TML [1980]|TML [198000]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183|71.22|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183|14.06|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNICARE [2040]|UNICARE [204000]|183||||183|14.06|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183|14.06|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WEB TPA [2115]|WEB TPA [211500]|183||||183|126.27|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183|0|139.08|14.06
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]|183||||183|0|139.08|14.06
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WORKER'S COMP [2125]|TML WC [212537]|183||||183|14.06|139.08|14.06
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AARP [1000]|AARP [100000]|450.5||||450.5||342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|64.69|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|324.36|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|225.25|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|225.25|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|342.38|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|138.66|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5||342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|64.69|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|Self-pay|Self-pay|450.5||||450.5|90.1|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|175.33|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5||342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5||342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5||342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5|0|342.38|64.69
31188162|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH OTHER SMEAR EXTENDED|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5||342.38|64.69
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|103.68||||103.68||78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103.68||||103.68|51.84|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103.68||||103.68|74.65|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103.68||||103.68|51.84|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103.68||||103.68|51.84|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103.68||||103.68|78.8|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|103.68||||103.68|41.47|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103.68||||103.68||78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103.68||||103.68|51.84|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|Self-pay|Self-pay|103.68||||103.68|20.74|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|TML [1980]|TML [198000]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103.68||||103.68|40.35|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103.68||||103.68||78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|103.68||||103.68||78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103.68||||103.68||78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|103.68||||103.68|71.54|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103.68||||103.68|0|78.8|20.74
31209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|103.68||||103.68||78.8|20.74
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AARP [1000]|AARP [100000]|88.5||||88.5|7.63|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AETNA [1015]|AETNA [101529]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AMBETTER [2930]|AMBETTER [293000]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|88.5||||88.5|32.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.5||||88.5|63.72|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.5||||88.5|44.25|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.5||||88.5|44.25|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|88.5||||88.5|67.26|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA [1260]|CIGNA PPO [126025]|88.5||||88.5|23.1|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|88.5||||88.5|7.63|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|88.5||||88.5|32.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|Self-pay|Self-pay|88.5||||88.5|17.7|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|TML [1980]|TML [198000]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.5||||88.5|34.44|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.5||||88.5|7.63|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UNICARE [2040]|UNICARE [204000]|88.5||||88.5|7.63|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.5||||88.5|7.63|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WEB TPA [2115]|WEB TPA [211500]|88.5||||88.5|61.07|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.5||||88.5|0|67.26|7.63
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WORKER'S COMP [2125]|TML WC [212537]|88.5||||88.5|7.63|67.26|7.63
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AARP [1000]|AARP [100000]|450.5||||450.5|14.06|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|32.07|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|324.36|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|225.25|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|225.25|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|342.38|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|54.68|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5|14.06|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|32.07|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|Self-pay|Self-pay|450.5||||450.5|90.1|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|175.33|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5|14.06|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5|14.06|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5|14.06|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5|0|342.38|14.06
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5|14.06|342.38|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AARP [1000]|AARP [100000]|211.75||||211.75|14.06|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA [1015]|AETNA [101529]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMBETTER [2930]|AMBETTER [293000]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|211.75||||211.75|64.69|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211.75||||211.75|152.46|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211.75||||211.75|105.88|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211.75||||211.75|105.88|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|211.75||||211.75|160.93|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA [1260]|CIGNA PPO [126025]|211.75||||211.75|73.95|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|211.75||||211.75|14.06|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|GROUP PENSION ADMIN [1450]|GPA [145000]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|211.75||||211.75|64.69|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|PHCS [1780]|PHCS MULTIPLAN [178000]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|Self-pay|Self-pay|211.75||||211.75|42.35|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|TML [1980]|TML [198000]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211.75||||211.75|82.41|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211.75||||211.75|14.06|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNICARE [2040]|UNICARE [204000]|211.75||||211.75|14.06|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211.75||||211.75|14.06|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WEB TPA [2115]|WEB TPA [211500]|211.75||||211.75|146.11|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211.75||||211.75|0|160.93|14.06
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WORKER'S COMP [2125]|TML WC [212537]|211.75||||211.75|14.06|160.93|14.06
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AARP [1000]|AARP [100000]|942.75||||942.75|22.86|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA [1015]|AETNA [101529]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMBETTER [2930]|AMBETTER [293000]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|942.75||||942.75|64.69|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|942.75||||942.75|678.78|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|942.75||||942.75|471.38|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|942.75||||942.75|471.38|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|942.75||||942.75|716.49|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA [1260]|CIGNA PPO [126025]|942.75||||942.75|73.95|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|942.75||||942.75|22.86|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|942.75||||942.75|64.69|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|Self-pay|Self-pay|942.75||||942.75|188.55|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|TML [1980]|TML [198000]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|942.75||||942.75|366.92|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|942.75||||942.75|22.86|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNICARE [2040]|UNICARE [204000]|942.75||||942.75|22.86|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|942.75||||942.75|22.86|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WEB TPA [2115]|WEB TPA [211500]|942.75||||942.75|650.5|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|942.75||||942.75|0|716.49|22.86
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WORKER'S COMP [2125]|TML WC [212537]|942.75||||942.75|22.86|716.49|22.86
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AARP [1000]|AARP [100000]|417||||417|36.27|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA [1015]|AETNA [101529]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMBETTER [2930]|AMBETTER [293000]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|417||||417|378.64|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|417||||417|300.24|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|417||||417|208.5|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|417||||417|208.5|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|417||||417|316.92|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA [1260]|CIGNA PPO [126025]|417||||417|417|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|417||||417|36.27|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|417||||417|378.64|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|Self-pay|Self-pay|417||||417|83.4|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|TML [1980]|TML [198000]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|417||||417|162.3|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|417||||417|36.27|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNICARE [2040]|UNICARE [204000]|417||||417|36.27|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|417||||417|36.27|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WEB TPA [2115]|WEB TPA [211500]|417||||417|287.73|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|417||||417|0|417|36.27
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WORKER'S COMP [2125]|TML WC [212537]|417||||417|36.27|417|36.27
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AARP [1000]|AARP [100000]|76.5||||76.5|7.63|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA [1015]|AETNA [101529]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMBETTER [2930]|AMBETTER [293000]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|76.5||||76.5|38.25|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.5||||76.5|55.08|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.5||||76.5|38.25|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.5||||76.5|38.25|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|76.5||||76.5|58.14|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA [1260]|CIGNA PPO [126025]|76.5||||76.5|18.5|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|76.5||||76.5|7.63|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|76.5||||76.5|38.25|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|Self-pay|Self-pay|76.5||||76.5|15.3|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|TML [1980]|TML [198000]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.5||||76.5|29.77|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.5||||76.5|7.63|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNICARE [2040]|UNICARE [204000]|76.5||||76.5|7.63|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.5||||76.5|7.63|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WEB TPA [2115]|WEB TPA [211500]|76.5||||76.5|52.79|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.5||||76.5|0|58.14|7.63
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WORKER'S COMP [2125]|TML WC [212537]|76.5||||76.5|7.63|58.14|7.63
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AARP [1000]|AARP [100000]|450.5||||450.5|14.06|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA [1015]|AETNA [101529]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMBETTER [2930]|AMBETTER [293000]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450.5||||450.5|64.69|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450.5||||450.5|324.36|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450.5||||450.5|225.25|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450.5||||450.5|225.25|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450.5||||450.5|342.38|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA [1260]|CIGNA PPO [126025]|450.5||||450.5|151.76|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450.5||||450.5|14.06|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450.5||||450.5|64.69|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|Self-pay|Self-pay|450.5||||450.5|90.1|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|TML [1980]|TML [198000]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450.5||||450.5|175.33|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450.5||||450.5|14.06|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNICARE [2040]|UNICARE [204000]|450.5||||450.5|14.06|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450.5||||450.5|14.06|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WEB TPA [2115]|WEB TPA [211500]|450.5||||450.5|310.85|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450.5||||450.5|0|342.38|14.06
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WORKER'S COMP [2125]|TML WC [212537]|450.5||||450.5|14.06|342.38|14.06
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AARP [1000]|AARP [100000]|50||||50||64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AETNA [1015]|AETNA [101529]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AMBETTER [2930]|AMBETTER [293000]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50||||50|64.69|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|36|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|25|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50||||50|38|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA [1260]|CIGNA PPO [126025]|50||||50|50|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50||||50||64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50||||50|64.69|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|Self-pay|Self-pay|50||||50|10|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|TML [1980]|TML [198000]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50|19.46|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50||64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UNICARE [2040]|UNICARE [204000]|50||||50||64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50||64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WEB TPA [2115]|WEB TPA [211500]|50||||50|34.5|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50|0|64.69|10
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WORKER'S COMP [2125]|TML WC [212537]|50||||50||64.69|10
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AARP [1000]|AARP [100000]|232.25||||232.25||193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AETNA [1015]|AETNA [101529]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AMBETTER [2930]|AMBETTER [293000]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|232.25||||232.25|193.91|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|232.25||||232.25|167.22|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|232.25||||232.25|116.13|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|232.25||||232.25|116.13|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|232.25||||232.25|176.51|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA [1260]|CIGNA PPO [126025]|232.25||||232.25|67.79|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|232.25||||232.25||193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|232.25||||232.25|193.91|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|Self-pay|Self-pay|232.25||||232.25|46.45|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|TML [1980]|TML [198000]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|232.25||||232.25|90.39|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|232.25||||232.25||193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UNICARE [2040]|UNICARE [204000]|232.25||||232.25||193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|232.25||||232.25||193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WEB TPA [2115]|WEB TPA [211500]|232.25||||232.25|160.25|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|232.25||||232.25|0|193.91|46.45
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WORKER'S COMP [2125]|TML WC [212537]|232.25||||232.25||193.91|46.45
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AARP [1000]|AARP [100000]|52||||52||52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA [1015]|AETNA [101529]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMBETTER [2930]|AMBETTER [293000]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52||||52|26|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52||||52|37.44|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52||||52|26|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52||||52|26|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52||||52|39.52|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA [1260]|CIGNA PPO [126025]|52||||52|52|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52||||52||52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52||||52|26|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|Self-pay|Self-pay|52||||52|10.4|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|TML [1980]|TML [198000]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52||||52|20.24|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52||||52||52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNICARE [2040]|UNICARE [204000]|52||||52||52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52||||52||52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WEB TPA [2115]|WEB TPA [211500]|52||||52|35.88|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52||||52|0|52|10.4
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]|52||||52|0|52|10.4
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WORKER'S COMP [2125]|TML WC [212537]|52||||52||52|10.4
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AARP [1000]|AARP [100000]|388||||388|22.86|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA [1015]|AETNA [101529]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMBETTER [2930]|AMBETTER [293000]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|388||||388|193.91|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|388||||388|279.36|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|388||||388|194|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|388||||388|194|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|388||||388|294.88|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA [1260]|CIGNA PPO [126025]|388||||388|150.97|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|388||||388|22.86|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|388||||388|193.91|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|Self-pay|Self-pay|388||||388|77.6|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|TML [1980]|TML [198000]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|388||||388|151.01|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|388||||388|22.86|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNICARE [2040]|UNICARE [204000]|388||||388|22.86|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|388||||388|22.86|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WEB TPA [2115]|WEB TPA [211500]|388||||388|267.72|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|388||||388|0|294.88|22.86
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WORKER'S COMP [2125]|TML WC [212537]|388||||388|22.86|294.88|22.86
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AARP [1000]|AARP [100000]|2020.4||||2020.4||1535.5|113.66
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]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AETNA [1015]|AETNA [101529]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMBETTER [2930]|AMBETTER [293000]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2020.4||||2020.4|786.34|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2020.4||||2020.4|113.66|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2020.4||||2020.4|786.34|1535.5|113.66
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]|2020.4||||2020.4|0|1535.5|113.66
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]|2020.4||||2020.4|1454.69|1535.5|113.66
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]|2020.4||||2020.4|1010.2|1535.5|113.66
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]|2020.4||||2020.4|1010.2|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2020.4||||2020.4|1535.5|1535.5|113.66
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]|2020.4||||2020.4|786.34|1535.5|113.66
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]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2020.4||||2020.4|1394.08|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA [1260]|CIGNA PPO [126025]|2020.4||||2020.4|808.16|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2020.4||||2020.4||1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2020.4||||2020.4|1394.08|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2020.4||||2020.4|113.66|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2020.4||||2020.4|1394.08|1535.5|113.66
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]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2020.4||||2020.4|786.34|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2020.4||||2020.4|0|1535.5|113.66
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]|2020.4||||2020.4|786.34|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2020.4||||2020.4|1394.08|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2020.4||||2020.4|786.34|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|Self-pay|Self-pay|2020.4||||2020.4|404.08|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|TML [1980]|TML [198000]|2020.4||||2020.4|1394.08|1535.5|113.66
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]|2020.4||||2020.4|786.34|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2020.4||||2020.4||1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNICARE [2040]|UNICARE [204000]|2020.4||||2020.4||1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2020.4||||2020.4||1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WEB TPA [2115]|WEB TPA [211500]|2020.4||||2020.4|1394.08|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2020.4||||2020.4|0|1535.5|113.66
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]|2020.4||||2020.4|0|1535.5|113.66
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WORKER'S COMP [2125]|TML WC [212537]|2020.4||||2020.4||1535.5|113.66
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.82||||2.82||2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.82||||2.82|1.41|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.82||||2.82|1.1|2.14|0.56
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]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.82||||2.82|2.03|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.82||||2.82|1.41|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.82||||2.82|1.41|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.82||||2.82|2.14|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.82||||2.82|1.95|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.82||||2.82|1.13|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.82||||2.82||2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.82||||2.82|1.95|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.82||||2.82|1.41|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.82||||2.82|1.95|2.14|0.56
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]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.82||||2.82|0|2.14|0.56
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]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.82||||2.82|1.95|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|Self-pay|Self-pay|2.82||||2.82|0.56|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.82||||2.82|1.95|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.82||||2.82|1.1|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.82||||2.82||2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.82||||2.82||2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.82||||2.82||2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.82||||2.82|1.95|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.82||||2.82|0|2.14|0.56
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]|2.82||||2.82|0|2.14|0.56
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.82||||2.82||2.14|0.56
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AARP [1000]|AARP [100000]|54555.6||||54555.6||41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AETNA [1015]|AETNA [101529]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AMBETTER [2930]|AMBETTER [293000]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|54555.6||||54555.6|5160.05|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54555.6||||54555.6|39280.03|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54555.6||||54555.6|27277.8|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54555.6||||54555.6|27277.8|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|54555.6||||54555.6|41462.26|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|CIGNA [1260]|CIGNA - GREAT WEST [126009]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|CIGNA [1260]|CIGNA PPO [126025]|54555.6||||54555.6|27277.8|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|54555.6||||54555.6||41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|GROUP PENSION ADMIN [1450]|GPA [145000]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|54555.6||||54555.6|5160.05|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|PHCS [1780]|PHCS MULTIPLAN [178000]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|Self-pay|Self-pay|54555.6||||54555.6|10911.12|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|TML [1980]|TML [198000]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54555.6||||54555.6|21233.04|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54555.6||||54555.6||41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|UNICARE [2040]|UNICARE [204000]|54555.6||||54555.6||41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54555.6||||54555.6||41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|WEB TPA [2115]|WEB TPA [211500]|54555.6||||54555.6|37643.36|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54555.6||||54555.6|0|41462.26|5160.05
31432|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION|1 vial|WORKER'S COMP [2125]|TML WC [212537]|54555.6||||54555.6||41462.26|5160.05
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AARP [1000]|AARP [100000]|480.95||||480.95||365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AETNA [1015]|AETNA [101529]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMBETTER [2930]|AMBETTER [293000]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|480.95||||480.95|240.48|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|480.95||||480.95|346.28|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|480.95||||480.95|240.48|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|480.95||||480.95|240.48|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|480.95||||480.95|365.52|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|CIGNA [1260]|CIGNA PPO [126025]|480.95||||480.95|192.38|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|480.95||||480.95||365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|480.95||||480.95|240.48|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|Self-pay|Self-pay|480.95||||480.95|96.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|TML [1980]|TML [198000]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|480.95||||480.95|187.19|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|480.95||||480.95||365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UNICARE [2040]|UNICARE [204000]|480.95||||480.95||365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|480.95||||480.95||365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WEB TPA [2115]|WEB TPA [211500]|480.95||||480.95|331.86|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|480.95||||480.95|0|365.52|96.19
3187|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL CREAM|1 each|WORKER'S COMP [2125]|TML WC [212537]|480.95||||480.95||365.52|96.19
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|871.2||||871.2|435.6|662.11|1.04
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]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMBETTER [2930]|AMBETTER [293000]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|871.2||||871.2|339.07|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|871.2||||871.2|1.04|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|871.2||||871.2|339.07|662.11|1.04
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]|871.2||||871.2|0|662.11|1.04
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]|871.2||||871.2|627.26|662.11|1.04
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]|871.2||||871.2|435.6|662.11|1.04
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]|871.2||||871.2|435.6|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|871.2||||871.2|662.11|662.11|1.04
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]|871.2||||871.2|339.07|662.11|1.04
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]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|871.2||||871.2|601.13|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA PPO [126025]|871.2||||871.2|348.48|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|871.2||||871.2|435.6|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|871.2||||871.2|601.13|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|871.2||||871.2|1.04|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|871.2||||871.2|601.13|662.11|1.04
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]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|871.2||||871.2|339.07|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|871.2||||871.2|0|662.11|1.04
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]|871.2||||871.2|339.07|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|871.2||||871.2|601.13|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|871.2||||871.2|339.07|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|871.2||||871.2|174.24|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TML [1980]|TML [198000]|871.2||||871.2|601.13|662.11|1.04
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]|871.2||||871.2|339.07|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|871.2||||871.2|435.6|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNICARE [2040]|UNICARE [204000]|871.2||||871.2|435.6|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|871.2||||871.2|435.6|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WEB TPA [2115]|WEB TPA [211500]|871.2||||871.2|601.13|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|871.2||||871.2|0|662.11|1.04
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]|871.2||||871.2|0|662.11|1.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TML WC [212537]|871.2||||871.2|435.6|662.11|1.04
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|1545.33||||1545.33|772.67|1174.45|309.07
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]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1545.33||||1545.33|601.44|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1545.33||||1545.33|601.44|1174.45|309.07
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]|1545.33||||1545.33|0|1174.45|309.07
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]|1545.33||||1545.33|1112.64|1174.45|309.07
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]|1545.33||||1545.33|772.67|1174.45|309.07
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]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1545.33||||1545.33|1174.45|1174.45|309.07
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]|1545.33||||1545.33|601.44|1174.45|309.07
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]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1545.33||||1545.33|1066.28|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|1545.33||||1545.33|618.13|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1545.33||||1545.33|1066.28|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1545.33||||1545.33|1066.28|1174.45|309.07
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]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1545.33||||1545.33|601.44|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1545.33||||1545.33|0|1174.45|309.07
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]|1545.33||||1545.33|601.44|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1545.33||||1545.33|1066.28|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1545.33||||1545.33|601.44|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|1545.33||||1545.33|309.07|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|1545.33||||1545.33|1066.28|1174.45|309.07
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]|1545.33||||1545.33|601.44|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1545.33||||1545.33|772.67|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|1545.33||||1545.33|1066.28|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1545.33||||1545.33|0|1174.45|309.07
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]|1545.33||||1545.33|0|1174.45|309.07
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|1545.33||||1545.33|772.67|1174.45|309.07
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AARP [1000]|AARP [100000]|824||||824||626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AETNA [1015]|AETNA [101529]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|824||||824|105.17|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|824||||824|593.28|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|824||||824|412|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|824||||824|412|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|824||||824|626.24|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|824||||824|198|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|824||||824||626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|824||||824|105.17|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|Self-pay|Self-pay|824||||824|164.8|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|TML [1980]|TML [198000]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|824||||824|49.42|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|824||||824||626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|UNICARE [2040]|UNICARE [204000]|824||||824||626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|824||||824||626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|824||||824|568.56|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|824||||824|0|626.24|49.42
32070100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE < 4 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|824||||824||626.24|49.42
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AARP [1000]|AARP [100000]|912||||912|88.55|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|912||||912|141.66|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|912||||912|656.64|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|912||||912|456|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|912||||912|456|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|912||||912|693.12|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|912||||912|327.9|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|912||||912|88.55|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|912||||912|141.66|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|Self-pay|Self-pay|912||||912|182.4|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|TML [1980]|TML [198000]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|912||||912|62.15|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|912||||912|88.55|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|912||||912|88.55|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|912||||912|88.55|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|912||||912|629.28|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|912||||912|0|693.12|62.15
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|912||||912|88.55|693.12|62.15
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AARP [1000]|AARP [100000]|1120||||1120||851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA [1015]|AETNA [101529]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMBETTER [2930]|AMBETTER [293000]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1120||||1120|299.17|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1120||||1120|806.4|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1120||||1120|560|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1120||||1120|560|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1120||||1120|851.2|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA [1260]|CIGNA PPO [126025]|1120||||1120|327.9|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1120||||1120||851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1120||||1120|299.17|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|Self-pay|Self-pay|1120||||1120|224|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|TML [1980]|TML [198000]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1120||||1120|133.88|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1120||||1120||851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNICARE [2040]|UNICARE [204000]|1120||||1120||851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1120||||1120||851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WEB TPA [2115]|WEB TPA [211500]|1120||||1120|772.8|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1120||||1120|0|851.2|133.88
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WORKER'S COMP [2125]|TML WC [212537]|1120||||1120||851.2|133.88
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AARP [1000]|AARP [100000]|748||||748|77.64|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AETNA [1015]|AETNA [101529]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AMBETTER [2930]|AMBETTER [293000]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|748||||748|105.17|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|748||||748|538.56|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|748||||748|374|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|748||||748|374|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|748||||748|568.48|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|748||||748|299.2|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|748||||748|77.64|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|748||||748|105.17|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|Self-pay|Self-pay|748||||748|149.6|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|TML [1980]|TML [198000]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|748||||748|32.93|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|748||||748|77.64|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UNICARE [2040]|UNICARE [204000]|748||||748|77.64|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|748||||748|77.64|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WEB TPA [2115]|WEB TPA [211500]|748||||748|516.12|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|748||||748|0|568.48|32.93
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|748||||748|77.64|568.48|32.93
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AARP [1000]|AARP [100000]|1050||||1050||798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1050||||1050|141.66|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1050||||1050|756|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1050||||1050|525|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1050||||1050|525|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1050||||1050|798|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|1050||||1050|420|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1050||||1050||798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1050||||1050|141.66|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|Self-pay|Self-pay|1050||||1050|210|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|TML [1980]|TML [198000]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1050||||1050|62.69|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1050||||1050||798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|1050||||1050||798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1050||||1050||798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|1050||||1050|724.5|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1050||||1050|0|798|62.69
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|1050||||1050||798|62.69
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AARP [1000]|AARP [100000]|912||||912|88.55|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AETNA [1015]|AETNA [101529]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AMBETTER [2930]|AMBETTER [293000]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|912||||912|141.66|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|912||||912|656.64|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|912||||912|456|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|912||||912|456|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|912||||912|693.12|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|912||||912|327.9|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|912||||912|88.55|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|912||||912|141.66|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|Self-pay|Self-pay|912||||912|182.4|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|TML [1980]|TML [198000]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|912||||912|57.38|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|912||||912|88.55|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UNICARE [2040]|UNICARE [204000]|912||||912|88.55|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|912||||912|88.55|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|WEB TPA [2115]|WEB TPA [211500]|912||||912|629.28|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|912||||912|0|693.12|57.38
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]|912||||912|0|693.12|57.38
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|912||||912|88.55|693.12|57.38
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AARP [1000]|AARP [100000]|907||||907|88.55|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AETNA [1015]|AETNA [101529]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|907||||907|141.66|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|907||||907|653.04|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|907||||907|453.5|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|907||||907|453.5|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|907||||907|689.32|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|907||||907|327.9|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|907||||907|88.55|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|907||||907|141.66|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|Self-pay|Self-pay|907||||907|181.4|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|TML [1980]|TML [198000]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|907||||907|68.02|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|907||||907|88.55|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UNICARE [2040]|UNICARE [204000]|907||||907|88.55|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|907||||907|88.55|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|907||||907|625.83|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|907||||907|0|689.32|68.02
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]|907||||907|0|689.32|68.02
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|907||||907|88.55|689.32|68.02
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AARP [1000]|AARP [100000]|824||||824|57.44|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|824||||824|105.17|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|824||||824|593.28|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|824||||824|412|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|824||||824|412|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|824||||824|626.24|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|824||||824|198|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|824||||824|57.44|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|824||||824|105.17|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|Self-pay|Self-pay|824||||824|164.8|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|TML [1980]|TML [198000]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|824||||824|42.5|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|824||||824|57.44|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|824||||824|57.44|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|824||||824|57.44|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|824||||824|568.56|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|824||||824|0|626.24|42.5
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|824||||824|57.44|626.24|42.5
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AARP [1000]|AARP [100000]|722||||722|57.44|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AETNA [1015]|AETNA [101529]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AMBETTER [2930]|AMBETTER [293000]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|722||||722|105.17|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|722||||722|519.84|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|722||||722|361|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|722||||722|361|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|722||||722|548.72|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|722||||722|198|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|722||||722|57.44|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|722||||722|105.17|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|Self-pay|Self-pay|722||||722|144.4|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|TML [1980]|TML [198000]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|722||||722|34.52|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|722||||722|57.44|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UNICARE [2040]|UNICARE [204000]|722||||722|57.44|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|722||||722|57.44|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WEB TPA [2115]|WEB TPA [211500]|722||||722|498.18|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|722||||722|0|548.72|34.52
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|722||||722|57.44|548.72|34.52
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AARP [1000]|AARP [100000]|824||||824|57.44|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|824||||824|105.17|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|824||||824|593.28|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|824||||824|412|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|824||||824|412|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|824||||824|626.24|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|824||||824|198|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|824||||824|57.44|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|824||||824|105.17|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|Self-pay|Self-pay|824||||824|164.8|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|TML [1980]|TML [198000]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|824||||824|43.57|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|824||||824|57.44|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|824||||824|57.44|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|824||||824|57.44|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|824||||824|568.56|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|824||||824|0|626.24|43.57
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|824||||824|57.44|626.24|43.57
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|912||||912|57.44|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|912||||912|105.17|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|912||||912|656.64|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|912||||912|456|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|912||||912|456|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|912||||912|693.12|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|912||||912|198|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|912||||912|57.44|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|912||||912|105.17|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|912||||912|182.4|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|TML [1980]|TML [198000]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|912||||912|52.6|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|912||||912|57.44|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|912||||912|57.44|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|912||||912|57.44|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|912||||912|629.28|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|912||||912|0|693.12|52.6
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|912||||912|57.44|693.12|52.6
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AARP [1000]|AARP [100000]|824||||824|57.44|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AETNA [1015]|AETNA [101529]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|824||||824|141.66|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|824||||824|593.28|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|824||||824|412|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|824||||824|412|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|824||||824|626.24|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|824||||824|327.9|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|824||||824|57.44|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|824||||824|141.66|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|Self-pay|Self-pay|824||||824|164.8|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|TML [1980]|TML [198000]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|824||||824|42.5|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|824||||824|57.44|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UNICARE [2040]|UNICARE [204000]|824||||824|57.44|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|824||||824|57.44|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|824||||824|568.56|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|824||||824|0|626.24|42.5
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|824||||824|57.44|626.24|42.5
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AARP [1000]|AARP [100000]|912||||912|57.44|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|912||||912|105.17|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|912||||912|656.64|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|912||||912|456|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|912||||912|456|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|912||||912|693.12|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|912||||912|198|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|912||||912|57.44|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|912||||912|105.17|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|Self-pay|Self-pay|912||||912|182.4|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|TML [1980]|TML [198000]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|912||||912|47.83|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|912||||912|57.44|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UNICARE [2040]|UNICARE [204000]|912||||912|57.44|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|912||||912|57.44|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|912||||912|629.28|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|912||||912|0|693.12|47.83
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|912||||912|57.44|693.12|47.83
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AARP [1000]|AARP [100000]|745||||745|77.64|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AETNA [1015]|AETNA [101529]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AMBETTER [2930]|AMBETTER [293000]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|745||||745|105.17|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|745||||745|536.4|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|745||||745|372.5|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|745||||745|372.5|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|745||||745|566.2|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA [1260]|CIGNA PPO [126025]|745||||745|298|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|745||||745|77.64|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|745||||745|105.17|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|Self-pay|Self-pay|745||||745|149|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|TML [1980]|TML [198000]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|745||||745|40.91|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|745||||745|77.64|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UNICARE [2040]|UNICARE [204000]|745||||745|77.64|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|745||||745|77.64|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WEB TPA [2115]|WEB TPA [211500]|745||||745|514.05|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|745||||745|0|566.2|40.91
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WORKER'S COMP [2125]|TML WC [212537]|745||||745|77.64|566.2|40.91
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AARP [1000]|AARP [100000]|1120||||1120|103.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AETNA [1015]|AETNA [101529]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AMBETTER [2930]|AMBETTER [293000]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1120||||1120|232.12|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1120||||1120|181.99|851.2|103.4
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]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1120||||1120|806.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1120||||1120|560|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1120||||1120|560|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1120||||1120|851.2|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1120||||1120|772.8|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA [1260]|CIGNA PPO [126025]|1120||||1120|327.9|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1120||||1120|103.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1120||||1120|772.8|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1120||||1120|232.12|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1120||||1120|772.8|851.2|103.4
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]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1120||||1120|0|851.2|103.4
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]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1120||||1120|772.8|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|Self-pay|Self-pay|1120||||1120|224|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|TML [1980]|TML [198000]|1120||||1120|772.8|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1120||||1120|181.99|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1120||||1120|103.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UNICARE [2040]|UNICARE [204000]|1120||||1120|103.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1120||||1120|103.4|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|WEB TPA [2115]|WEB TPA [211500]|1120||||1120|772.8|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1120||||1120|0|851.2|103.4
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]|1120||||1120|0|851.2|103.4
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|WORKER'S COMP [2125]|TML WC [212537]|1120||||1120|103.4|851.2|103.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AARP [1000]|AARP [100000]|492||||492||373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AETNA [1015]|AETNA [101529]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AMBETTER [2930]|AMBETTER [293000]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|492||||492|232.12|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|492||||492|354.24|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|492||||492|246|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|492||||492|246|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|492||||492|373.92|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA [1260]|CIGNA PPO [126025]|492||||492|327.9|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|492||||492||373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|492||||492|232.12|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|Self-pay|Self-pay|492||||492|98.4|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|TML [1980]|TML [198000]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|492||||492|189.67|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|492||||492||373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UNICARE [2040]|UNICARE [204000]|492||||492||373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|492||||492||373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WEB TPA [2115]|WEB TPA [211500]|492||||492|339.48|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|492||||492|0|373.92|98.4
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WORKER'S COMP [2125]|TML WC [212537]|492||||492||373.92|98.4
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AARP [1000]|AARP [100000]|250||||250||190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AETNA [1015]|AETNA [101529]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AMBETTER [2930]|AMBETTER [293000]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|250||||250|125|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|250||||250|180|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|250||||250|125|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|250||||250|125|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|250||||250|190|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA [1260]|CIGNA PPO [126025]|250||||250|100|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|250||||250||190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|250||||250|125|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|Self-pay|Self-pay|250||||250|50|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|TML [1980]|TML [198000]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|250||||250|123.24|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|250||||250||190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UNICARE [2040]|UNICARE [204000]|250||||250||190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|250||||250||190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|WEB TPA [2115]|WEB TPA [211500]|250||||250|172.5|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|250||||250|0|190|50
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]|250||||250|0|190|50
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|WORKER'S COMP [2125]|TML WC [212537]|250||||250||190|50
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AARP [1000]|AARP [100000]|2251||||2251||1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AETNA [1015]|AETNA [101529]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AMBETTER [2930]|AMBETTER [293000]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2251||||2251|1125.5|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2251||||2251|1620.72|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2251||||2251|1125.5|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2251||||2251|1125.5|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2251||||2251|1710.76|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|CIGNA [1260]|CIGNA PPO [126025]|2251||||2251|900.4|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2251||||2251||1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2251||||2251|1125.5|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|Self-pay|Self-pay|2251||||2251|450.2|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|TML [1980]|TML [198000]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2251||||2251|876.09|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2251||||2251||1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|UNICARE [2040]|UNICARE [204000]|2251||||2251||1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2251||||2251||1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|WEB TPA [2115]|WEB TPA [211500]|2251||||2251|1553.19|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2251||||2251|0|1710.76|450.2
32074330|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ERCP-BILIARY/PANCREATIC SYSTEM|1|WORKER'S COMP [2125]|TML WC [212537]|2251||||2251||1710.76|450.2
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AARP [1000]|AARP [100000]|999||||999||759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AETNA [1015]|AETNA [101529]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AMBETTER [2930]|AMBETTER [293000]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|999||||999|499.5|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|999||||999|719.28|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|999||||999|499.5|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|999||||999|499.5|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|999||||999|759.24|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|CIGNA [1260]|CIGNA PPO [126025]|999||||999|399.6|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|999||||999||759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|999||||999|499.5|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|Self-pay|Self-pay|999||||999|199.8|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|TML [1980]|TML [198000]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|999||||999|388.81|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|999||||999||759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|UNICARE [2040]|UNICARE [204000]|999||||999||759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|999||||999||759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|WEB TPA [2115]|WEB TPA [211500]|999||||999|689.31|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|999||||999|0|759.24|199.8
32077001|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO GUIDNC RMVL/PLCMNT S&I|1|WORKER'S COMP [2125]|TML WC [212537]|999||||999||759.24|199.8
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|304.66||||304.66||231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|304.66||||304.66|2.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304.66||||304.66|219.36|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304.66||||304.66|152.33|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304.66||||304.66|152.33|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|304.66||||304.66|231.54|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|304.66||||304.66|121.86|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|304.66||||304.66||231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|304.66||||304.66|2.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|Self-pay|Self-pay|304.66||||304.66|60.93|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|TML [1980]|TML [198000]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304.66||||304.66|118.57|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304.66||||304.66||231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UNICARE [2040]|UNICARE [204000]|304.66||||304.66||231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304.66||||304.66||231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|304.66||||304.66|210.22|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304.66||||304.66|0|231.54|2.22
32215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|304.66||||304.66||231.54|2.22
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AARP [1000]|AARP [100000]|824||||824|57.44|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AETNA [1015]|AETNA [101529]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AMBETTER [2930]|AMBETTER [293000]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|824||||824|105.17|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|824||||824|593.28|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|824||||824|412|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|824||||824|412|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|824||||824|626.24|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA [1260]|CIGNA PPO [126025]|824||||824|198|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|824||||824|57.44|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|824||||824|105.17|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|Self-pay|Self-pay|824||||824|164.8|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|TML [1980]|TML [198000]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|824||||824|38.78|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|824||||824|57.44|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UNICARE [2040]|UNICARE [204000]|824||||824|57.44|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|824||||824|57.44|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WEB TPA [2115]|WEB TPA [211500]|824||||824|568.56|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|824||||824|0|626.24|38.78
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WORKER'S COMP [2125]|TML WC [212537]|824||||824|57.44|626.24|38.78
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|12.99||||12.99||9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMBETTER [2930]|AMBETTER [293000]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.99||||12.99|6.5|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.99||||12.99|9.35|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.99||||12.99|6.5|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.99||||12.99|6.5|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.99||||12.99|9.87|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA PPO [126025]|12.99||||12.99|5.2|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.99||||12.99||9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.99||||12.99|6.5|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|12.99||||12.99|2.6|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|TML [1980]|TML [198000]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.99||||12.99|5.06|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.99||||12.99||9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UNICARE [2040]|UNICARE [204000]|12.99||||12.99||9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.99||||12.99||9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WEB TPA [2115]|WEB TPA [211500]|12.99||||12.99|8.96|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.99||||12.99|0|9.87|2.6
3232|ERX|0250 - PHARMACY-GENERAL|FOLIC ACID 5 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TML WC [212537]|12.99||||12.99||9.87|2.6
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.01||||2.01||1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.01||||2.01|1.01|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.01||||2.01|0.78|1.53|0.4
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]|2.01||||2.01|0|1.53|0.4
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]|2.01||||2.01|1.45|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.01||||2.01|1.01|1.53|0.4
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]|2.01||||2.01|1.01|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.01||||2.01|1.53|1.53|0.4
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]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.01||||2.01|1.39|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.01||||2.01|0.8|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.01||||2.01||1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.01||||2.01|1.39|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.01||||2.01|1.01|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.01||||2.01|1.39|1.53|0.4
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]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.01||||2.01|0|1.53|0.4
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]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.01||||2.01|1.39|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.01||||2.01|0.4|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.01||||2.01|1.39|1.53|0.4
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]|2.01||||2.01|0.78|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.01||||2.01||1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.01||||2.01||1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.01||||2.01||1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.01||||2.01|1.39|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.01||||2.01|0|1.53|0.4
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]|2.01||||2.01|0|1.53|0.4
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.01||||2.01||1.53|0.4
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.11||||1.11||0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.11||||1.11|0.56|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.11||||1.11|0.8|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.11||||1.11|0.56|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.11||||1.11|0.56|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.11||||1.11|0.84|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.11||||1.11|0.44|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.11||||1.11||0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.11||||1.11|0.56|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|1.11||||1.11|0.22|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.11||||1.11|0.43|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.11||||1.11||0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.11||||1.11||0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.11||||1.11||0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.11||||1.11|0.77|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.11||||1.11|0|0.84|0.22
324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.11||||1.11||0.84|0.22
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.65||||0.65||0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.65||||0.65|0.33|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.65||||0.65|0.47|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.65||||0.65|0.33|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.65||||0.65|0.33|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.65||||0.65|0.49|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.65||||0.65|0.26|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.65||||0.65||0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.65||||0.65|0.33|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.65||||0.65|0.13|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.65||||0.65|0.25|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.65||||0.65||0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.65||||0.65||0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.65||||0.65||0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.65||||0.65|0.45|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.65||||0.65|0|0.49|0.13
325|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALPRAZOLAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.65||||0.65||0.49|0.13
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]|356.4||||356.4||270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|356.4||||356.4|13.91|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|256.61|270.86|13.91
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]|356.4||||356.4|178.2|270.86|13.91
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]|356.4||||356.4|178.2|270.86|13.91
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 TRADITIONAL OF TEXAS [115503]|356.4||||356.4|270.86|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|356.4||||356.4|245.92|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|356.4||||356.4|142.56|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|356.4||||356.4||270.86|13.91
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]|356.4||||356.4|245.92|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|356.4||||356.4|13.91|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|356.4||||356.4|245.92|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4|245.92|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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|356.4||||356.4|71.28|270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|TML [1980]|TML [198000]|356.4||||356.4|245.92|270.86|13.91
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]|356.4||||356.4|138.71|270.86|13.91
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]|356.4||||356.4||270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|356.4||||356.4||270.86|13.91
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]|356.4||||356.4||270.86|13.91
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|356.4||||356.4|245.92|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|356.4||||356.4|0|270.86|13.91
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]|TML WC [212537]|356.4||||356.4||270.86|13.91
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|19.17||||19.17|9.59|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.17||||19.17|0.85|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.17||||19.17|0.85|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.17||||19.17|7.46|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|13.8|14.57|0.85
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]|19.17||||19.17|13.8|14.57|0.85
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]|19.17||||19.17|9.59|14.57|0.85
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]|19.17||||19.17|9.59|14.57|0.85
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]|19.17||||19.17|9.59|14.57|0.85
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]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.17||||19.17|14.57|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.17||||19.17|14.57|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|19.17||||19.17|7.67|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|19.17||||19.17|7.67|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.17||||19.17|0.85|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.17||||19.17|0.85|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.17||||19.17|13.23|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|19.17||||19.17|3.83|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|19.17||||19.17|3.83|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|19.17||||19.17|13.23|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
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]|19.17||||19.17|7.46|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|19.17||||19.17|13.23|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
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]|19.17||||19.17|0|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|19.17||||19.17|9.59|14.57|0.85
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|19.17||||19.17|9.59|14.57|0.85
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.66||||0.66||0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.66||||0.66|0.33|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.66||||0.66|0.26|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.48|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.33|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.33|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.66||||0.66|0.5|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.66||||0.66|0.46|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.66||||0.66||0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.66||||0.66|0.33|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.66||||0.66|0.46|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0|0.5|0.13
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]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.66||||0.66|0.13|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.66||||0.66|0.46|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.26|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66||0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.66||||0.66||0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66||0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.66||||0.66|0.46|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66|0|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.66||||0.66||0.5|0.13
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.9||||0.9||0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.9||||0.9|0.45|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.9||||0.9|0.35|0.68|0.18
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]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.9||||0.9|0.65|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.9||||0.9|0.45|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.9||||0.9|0.45|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.9||||0.9|0.68|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.9||||0.9|0.62|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.9||||0.9|0.36|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.9||||0.9||0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.9||||0.9|0.62|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.9||||0.9|0.45|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.9||||0.9|0.62|0.68|0.18
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]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.9||||0.9|0|0.68|0.18
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]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.9||||0.9|0.62|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|Self-pay|Self-pay|0.9||||0.9|0.18|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.9||||0.9|0.62|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.9||||0.9|0.35|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.9||||0.9||0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.9||||0.9||0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.9||||0.9||0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.9||||0.9|0.62|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.9||||0.9|0|0.68|0.18
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]|0.9||||0.9|0|0.68|0.18
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.9||||0.9||0.68|0.18
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|225.22||||225.22||171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMBETTER [2930]|AMBETTER [293000]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|225.22||||225.22|112.61|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|225.22||||225.22|87.66|171.17|45.04
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]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225.22||||225.22|162.16|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225.22||||225.22|112.61|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225.22||||225.22|112.61|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|225.22||||225.22|171.17|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|225.22||||225.22|155.4|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA [1260]|CIGNA PPO [126025]|225.22||||225.22|90.09|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|225.22||||225.22||171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|225.22||||225.22|155.4|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|225.22||||225.22|112.61|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|225.22||||225.22|155.4|171.17|45.04
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]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225.22||||225.22|0|171.17|45.04
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]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|225.22||||225.22|155.4|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|Self-pay|Self-pay|225.22||||225.22|45.04|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|TML [1980]|TML [198000]|225.22||||225.22|155.4|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225.22||||225.22|87.66|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225.22||||225.22||171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNICARE [2040]|UNICARE [204000]|225.22||||225.22||171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225.22||||225.22||171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WEB TPA [2115]|WEB TPA [211500]|225.22||||225.22|155.4|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225.22||||225.22|0|171.17|45.04
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]|225.22||||225.22|0|171.17|45.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WORKER'S COMP [2125]|TML WC [212537]|225.22||||225.22||171.17|45.04
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|48.67||||48.67||36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48.67||||48.67|24.34|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.67||||48.67|35.04|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.67||||48.67|24.34|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.67||||48.67|24.34|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48.67||||48.67|36.99|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|48.67||||48.67|19.47|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48.67||||48.67||36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48.67||||48.67|24.34|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|Self-pay|Self-pay|48.67||||48.67|9.73|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.67||||48.67|18.94|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.67||||48.67||36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|48.67||||48.67||36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.67||||48.67||36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|48.67||||48.67|33.58|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.67||||48.67|0|36.99|9.73
33009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|48.67||||48.67||36.99|9.73
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AARP [1000]|AARP [100000]|966.77||||966.77||734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AETNA [1015]|AETNA [101529]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AMBETTER [2930]|AMBETTER [293000]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|966.77||||966.77|2.15|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|966.77||||966.77|376.27|734.75|2.15
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]|966.77||||966.77|0|734.75|2.15
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]|966.77||||966.77|696.07|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|966.77||||966.77|483.39|734.75|2.15
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]|966.77||||966.77|483.39|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|966.77||||966.77|734.75|734.75|2.15
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]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|966.77||||966.77|667.07|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA [1260]|CIGNA PPO [126025]|966.77||||966.77|386.71|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|966.77||||966.77||734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|966.77||||966.77|667.07|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|966.77||||966.77|2.15|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|966.77||||966.77|667.07|734.75|2.15
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]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|966.77||||966.77|0|734.75|2.15
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]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|966.77||||966.77|667.07|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|Self-pay|Self-pay|966.77||||966.77|193.35|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|TML [1980]|TML [198000]|966.77||||966.77|667.07|734.75|2.15
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]|966.77||||966.77|376.27|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|966.77||||966.77||734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UNICARE [2040]|UNICARE [204000]|966.77||||966.77||734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|966.77||||966.77||734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|WEB TPA [2115]|WEB TPA [211500]|966.77||||966.77|667.07|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|966.77||||966.77|0|734.75|2.15
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]|966.77||||966.77|0|734.75|2.15
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|WORKER'S COMP [2125]|TML WC [212537]|966.77||||966.77||734.75|2.15
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AARP [1000]|AARP [100000]|721.62||||721.62||548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AETNA [1015]|AETNA [101529]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMBETTER [2930]|AMBETTER [293000]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|721.62||||721.62|27.24|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|721.62||||721.62|280.85|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|519.57|548.43|27.24
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]|721.62||||721.62|360.81|548.43|27.24
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]|721.62||||721.62|360.81|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|721.62||||721.62|548.43|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|721.62||||721.62|497.92|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA [1260]|CIGNA PPO [126025]|721.62||||721.62|288.65|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|721.62||||721.62||548.43|27.24
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]|721.62||||721.62|497.92|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|721.62||||721.62|27.24|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|721.62||||721.62|497.92|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|721.62||||721.62|497.92|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|Self-pay|Self-pay|721.62||||721.62|144.32|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|TML [1980]|TML [198000]|721.62||||721.62|497.92|548.43|27.24
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]|721.62||||721.62|280.85|548.43|27.24
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]|721.62||||721.62||548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNICARE [2040]|UNICARE [204000]|721.62||||721.62||548.43|27.24
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]|721.62||||721.62||548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WEB TPA [2115]|WEB TPA [211500]|721.62||||721.62|497.92|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
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]|721.62||||721.62|0|548.43|27.24
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WORKER'S COMP [2125]|TML WC [212537]|721.62||||721.62||548.43|27.24
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.63||||18.63||14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.63||||18.63|9.32|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.63||||18.63|13.41|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.63||||18.63|9.32|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.63||||18.63|9.32|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.63||||18.63|14.16|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.63||||18.63|7.45|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.63||||18.63||14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.63||||18.63|9.32|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|Self-pay|Self-pay|18.63||||18.63|3.73|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.63||||18.63|7.25|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.63||||18.63||14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.63||||18.63||14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.63||||18.63||14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.63||||18.63|12.85|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.63||||18.63|0|14.16|3.73
33227|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.63||||18.63||14.16|3.73
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|22.29||||22.29||16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|22.29||||22.29|11.15|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|22.29||||22.29|8.68|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|16.05|16.94|4.46
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]|22.29||||22.29|11.15|16.94|4.46
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]|22.29||||22.29|11.15|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|22.29||||22.29|16.94|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|22.29||||22.29|15.38|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|22.29||||22.29|8.92|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|22.29||||22.29||16.94|4.46
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]|22.29||||22.29|15.38|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|22.29||||22.29|11.15|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|22.29||||22.29|15.38|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|22.29||||22.29|15.38|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|Self-pay|Self-pay|22.29||||22.29|4.46|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|TML [1980]|TML [198000]|22.29||||22.29|15.38|16.94|4.46
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]|22.29||||22.29|8.68|16.94|4.46
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]|22.29||||22.29||16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|22.29||||22.29||16.94|4.46
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]|22.29||||22.29||16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|22.29||||22.29|15.38|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
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]|22.29||||22.29|0|16.94|4.46
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|22.29||||22.29||16.94|4.46
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AARP [1000]|AARP [100000]|142.56||||142.56||108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AETNA [1015]|AETNA [101529]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMBETTER [2930]|AMBETTER [293000]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|142.56||||142.56|71.28|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.56||||142.56|102.64|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.56||||142.56|71.28|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.56||||142.56|71.28|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|142.56||||142.56|108.35|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|142.56||||142.56|57.02|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|142.56||||142.56||108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|142.56||||142.56|71.28|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|Self-pay|Self-pay|142.56||||142.56|28.51|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|TML [1980]|TML [198000]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.56||||142.56|55.48|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.56||||142.56||108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UNICARE [2040]|UNICARE [204000]|142.56||||142.56||108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.56||||142.56||108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WEB TPA [2115]|WEB TPA [211500]|142.56||||142.56|98.37|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.56||||142.56|0|108.35|28.51
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|142.56||||142.56||108.35|28.51
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.16||||3.16||2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.16||||3.16|1.58|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.16||||3.16|1.23|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.16||||3.16|2.28|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.16||||3.16|1.58|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.16||||3.16|1.58|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.16||||3.16|2.4|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.16||||3.16|2.18|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.16||||3.16|1.26|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.16||||3.16||2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.16||||3.16|2.18|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.16||||3.16|1.58|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.16||||3.16|2.18|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.16||||3.16|0|2.4|0.63
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]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.16||||3.16|2.18|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.16||||3.16|0.63|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.16||||3.16|2.18|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.16||||3.16|1.23|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.16||||3.16||2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.16||||3.16||2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.16||||3.16||2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.16||||3.16|2.18|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.16||||3.16|0|2.4|0.63
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]|3.16||||3.16|0|2.4|0.63
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.16||||3.16||2.4|0.63
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|100.25||||100.25||76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|100.25||||100.25|50.13|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|100.25||||100.25|72.18|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|100.25||||100.25|50.13|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|100.25||||100.25|50.13|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|100.25||||100.25|76.19|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|100.25||||100.25|40.1|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|100.25||||100.25||76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|100.25||||100.25|50.13|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|100.25||||100.25|20.05|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|100.25||||100.25|39.02|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|100.25||||100.25||76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|100.25||||100.25||76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|100.25||||100.25||76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|100.25||||100.25|69.17|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|100.25||||100.25|0|76.19|20.05
34089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DUTASTERIDE 0.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|100.25||||100.25||76.19|20.05
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AARP [1000]|AARP [100000]|5357||||5357||4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AETNA [1015]|AETNA [101529]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMBETTER [2930]|AMBETTER [293000]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5357||||5357|1697.72|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|3857.04|4071.32|1071.4
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]|5357||||5357|2678.5|4071.32|1071.4
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]|5357||||5357|2678.5|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5357||||5357|4071.32|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5357||||5357|3696.33|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA [1260]|CIGNA PPO [126025]|5357||||5357|2142.8|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5357||||5357||4071.32|1071.4
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]|5357||||5357|3696.33|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5357||||5357|1697.72|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5357||||5357|3696.33|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357|3696.33|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|Self-pay|Self-pay|5357||||5357|1071.4|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|TML [1980]|TML [198000]|5357||||5357|3696.33|4071.32|1071.4
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]|5357||||5357|1081.14|4071.32|1071.4
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]|5357||||5357||4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNICARE [2040]|UNICARE [204000]|5357||||5357||4071.32|1071.4
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]|5357||||5357||4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WEB TPA [2115]|WEB TPA [211500]|5357||||5357|3696.33|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
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]|5357||||5357|0|4071.32|1071.4
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WORKER'S COMP [2125]|TML WC [212537]|5357||||5357||4071.32|1071.4
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AARP [1000]|AARP [100000]|1042.67||||1042.67||792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA [101529]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AMBETTER [2930]|AMBETTER [293000]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1042.67||||1042.67|521.34|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1042.67||||1042.67|750.72|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1042.67||||1042.67|521.34|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1042.67||||1042.67|521.34|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1042.67||||1042.67|792.43|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA PPO [126025]|1042.67||||1042.67|417.07|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1042.67||||1042.67||792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1042.67||||1042.67|521.34|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|Self-pay|Self-pay|1042.67||||1042.67|208.53|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|TML [1980]|TML [198000]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1042.67||||1042.67|405.81|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1042.67||||1042.67||792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|UNICARE [2040]|UNICARE [204000]|1042.67||||1042.67||792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1042.67||||1042.67||792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|WEB TPA [2115]|WEB TPA [211500]|1042.67||||1042.67|719.44|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1042.67||||1042.67|0|792.43|208.53
3423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.1 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TML WC [212537]|1042.67||||1042.67||792.43|208.53
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|42.64||||42.64|21.32|32.41|2.31
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]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.64||||42.64|16.6|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|42.64||||42.64|2.31|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|42.64||||42.64|16.6|32.41|2.31
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]|42.64||||42.64|0|32.41|2.31
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]|42.64||||42.64|30.7|32.41|2.31
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]|42.64||||42.64|21.32|32.41|2.31
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]|42.64||||42.64|21.32|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|42.64||||42.64|32.41|32.41|2.31
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]|42.64||||42.64|16.6|32.41|2.31
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]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|42.64||||42.64|29.42|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|42.64||||42.64|17.06|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|42.64||||42.64|21.32|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|42.64||||42.64|29.42|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|42.64||||42.64|2.31|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|42.64||||42.64|29.42|32.41|2.31
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]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.64||||42.64|16.6|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.64||||42.64|0|32.41|2.31
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]|42.64||||42.64|16.6|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|42.64||||42.64|29.42|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.64||||42.64|16.6|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|42.64||||42.64|8.53|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|42.64||||42.64|29.42|32.41|2.31
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]|42.64||||42.64|16.6|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.64||||42.64|21.32|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|42.64||||42.64|21.32|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.64||||42.64|21.32|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|42.64||||42.64|29.42|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.64||||42.64|0|32.41|2.31
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]|42.64||||42.64|0|32.41|2.31
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|42.64||||42.64|21.32|32.41|2.31
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|411.32||||411.32||312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|411.32||||411.32|205.66|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|296.15|312.6|82.26
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]|411.32||||411.32|205.66|312.6|82.26
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]|411.32||||411.32|205.66|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|411.32||||411.32|312.6|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|411.32||||411.32|283.81|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA PPO [126025]|411.32||||411.32|164.53|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|411.32||||411.32||312.6|82.26
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]|411.32||||411.32|283.81|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|411.32||||411.32|205.66|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|411.32||||411.32|283.81|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32|283.81|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|Self-pay|Self-pay|411.32||||411.32|82.26|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|411.32||||411.32|283.81|312.6|82.26
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]|411.32||||411.32|160.09|312.6|82.26
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]|411.32||||411.32||312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|411.32||||411.32||312.6|82.26
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]|411.32||||411.32||312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|411.32||||411.32|283.81|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
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]|411.32||||411.32|0|312.6|82.26
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TML WC [212537]|411.32||||411.32||312.6|82.26
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]|304.26||||304.26|152.13|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|304.26||||304.26|0.16|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|219.07|231.24|0.16
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]|304.26||||304.26|152.13|231.24|0.16
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]|304.26||||304.26|152.13|231.24|0.16
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 TRADITIONAL OF TEXAS [115503]|304.26||||304.26|231.24|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|304.26||||304.26|209.94|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|304.26||||304.26|121.7|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|304.26||||304.26|152.13|231.24|0.16
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]|304.26||||304.26|209.94|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|304.26||||304.26|0.16|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|304.26||||304.26|209.94|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|209.94|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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|304.26||||304.26|60.85|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|TML [1980]|TML [198000]|304.26||||304.26|209.94|231.24|0.16
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]|304.26||||304.26|118.42|231.24|0.16
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]|304.26||||304.26|152.13|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNICARE [2040]|UNICARE [204000]|304.26||||304.26|152.13|231.24|0.16
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]|304.26||||304.26|152.13|231.24|0.16
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|304.26||||304.26|209.94|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|304.26||||304.26|0|231.24|0.16
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]|TML WC [212537]|304.26||||304.26|152.13|231.24|0.16
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|57.56||||57.56||43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|57.56||||57.56|28.78|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|57.56||||57.56|22.4|43.75|11.51
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]|57.56||||57.56|0|43.75|11.51
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]|57.56||||57.56|41.44|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.56||||57.56|28.78|43.75|11.51
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]|57.56||||57.56|28.78|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|57.56||||57.56|43.75|43.75|11.51
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]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|57.56||||57.56|39.72|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|57.56||||57.56|23.02|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|57.56||||57.56||43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|57.56||||57.56|39.72|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|57.56||||57.56|28.78|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|57.56||||57.56|39.72|43.75|11.51
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]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.56||||57.56|0|43.75|11.51
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]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|57.56||||57.56|39.72|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|57.56||||57.56|11.51|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|57.56||||57.56|39.72|43.75|11.51
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]|57.56||||57.56|22.4|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.56||||57.56||43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|57.56||||57.56||43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.56||||57.56||43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|57.56||||57.56|39.72|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.56||||57.56|0|43.75|11.51
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]|57.56||||57.56|0|43.75|11.51
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|57.56||||57.56||43.75|11.51
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.24||||9.24||7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.24||||9.24|4.62|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.24||||9.24|6.65|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.24||||9.24|4.62|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.24||||9.24|4.62|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.24||||9.24|7.02|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.24||||9.24|6.38|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.24||||9.24|3.7|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.24||||9.24||7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.24||||9.24|6.38|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.24||||9.24|4.62|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.24||||9.24|6.38|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|Self-pay|Self-pay|9.24||||9.24|1.85|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.24||||9.24|6.38|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.24||||9.24|3.6|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.24||||9.24||7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.24||||9.24||7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.24||||9.24||7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.24||||9.24|6.38|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.24||||9.24|4.62|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.24||||9.24|3.6|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.24||||9.24|6.65|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.24||||9.24|4.62|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.24||||9.24|4.62|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.24||||9.24|7.02|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.24||||9.24|6.38|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.24||||9.24|3.7|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.24||||9.24|6.38|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.24||||9.24|4.62|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.24||||9.24|6.38|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.24||||9.24|6.38|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|Self-pay|Self-pay|9.24||||9.24|1.85|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.24||||9.24|6.38|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.24||||9.24|3.6|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.24||||9.24||7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.24||||9.24|6.38|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.24||||9.24|0|7.02|1.85
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]|9.24||||9.24|0|7.02|1.85
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.24||||9.24||7.02|1.85
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|44.28||||44.28||33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.28||||44.28|22.14|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|31.88|33.65|8.86
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]|44.28||||44.28|22.14|33.65|8.86
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]|44.28||||44.28|22.14|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|44.28||||44.28|33.65|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|44.28||||44.28|30.55|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|44.28||||44.28|17.71|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.28||||44.28||33.65|8.86
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]|44.28||||44.28|30.55|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.28||||44.28|22.14|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.28||||44.28|30.55|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28|30.55|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|44.28||||44.28|8.86|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|44.28||||44.28|30.55|33.65|8.86
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]|44.28||||44.28|17.23|33.65|8.86
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]|44.28||||44.28||33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|44.28||||44.28||33.65|8.86
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]|44.28||||44.28||33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|44.28||||44.28|30.55|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
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]|44.28||||44.28|0|33.65|8.86
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|44.28||||44.28||33.65|8.86
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.8||||4.8||3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.8||||4.8|2.4|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.8||||4.8|1.87|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|3.46|3.65|0.96
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]|4.8||||4.8|2.4|3.65|0.96
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]|4.8||||4.8|2.4|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.8||||4.8|3.65|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.8||||4.8|3.31|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.8||||4.8|1.92|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.8||||4.8||3.65|0.96
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]|4.8||||4.8|3.31|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.8||||4.8|2.4|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.8||||4.8|3.31|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.8||||4.8|3.31|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|4.8||||4.8|0.96|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.8||||4.8|3.31|3.65|0.96
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]|4.8||||4.8|1.87|3.65|0.96
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]|4.8||||4.8||3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.8||||4.8||3.65|0.96
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]|4.8||||4.8||3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.8||||4.8|3.31|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
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]|4.8||||4.8|0|3.65|0.96
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.8||||4.8||3.65|0.96
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AARP [1000]|AARP [100000]|3131||||3131||2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AETNA [1015]|AETNA [101529]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMBETTER [2930]|AMBETTER [293000]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3131||||3131|1565.5|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3131||||3131|2254.32|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3131||||3131|1565.5|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3131||||3131|1565.5|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3131||||3131|2379.56|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|CIGNA [1260]|CIGNA PPO [126025]|3131||||3131|1252.4|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3131||||3131||2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3131||||3131|1565.5|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|Self-pay|Self-pay|3131||||3131|626.2|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|TML [1980]|TML [198000]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3131||||3131|1218.59|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3131||||3131||2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UNICARE [2040]|UNICARE [204000]|3131||||3131||2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3131||||3131||2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WEB TPA [2115]|WEB TPA [211500]|3131||||3131|2160.39|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3131||||3131|0|2379.56|626.2
35000420|EAP|0350 - CT SCAN-GENERAL|HC CT CEREBRAL PERFUSION ANAL W/CONT|1|WORKER'S COMP [2125]|TML WC [212537]|3131||||3131||2379.56|626.2
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.5||||2.5||1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.5||||2.5|1.25|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.5||||2.5|0.97|1.9|0.5
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]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.5||||2.5|1.8|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.5||||2.5|1.25|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.5||||2.5|1.25|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.5||||2.5|1.9|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.5||||2.5|1.73|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.5||||2.5|1|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.5||||2.5||1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.5||||2.5|1.73|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.5||||2.5|1.25|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.5||||2.5|1.73|1.9|0.5
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]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.5||||2.5|0|1.9|0.5
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]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.5||||2.5|1.73|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.5||||2.5|0.5|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.5||||2.5|1.73|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.5||||2.5|0.97|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.5||||2.5||1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.5||||2.5||1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.5||||2.5||1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.5||||2.5|1.73|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.5||||2.5|0|1.9|0.5
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]|2.5||||2.5|0|1.9|0.5
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.5||||2.5||1.9|0.5
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.48||||18.48||14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.48||||18.48|9.24|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.48||||18.48|7.19|14.04|3.7
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]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.48||||18.48|13.31|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.48||||18.48|9.24|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.48||||18.48|9.24|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.48||||18.48|14.04|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.48||||18.48|12.75|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.48||||18.48|7.39|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.48||||18.48||14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.48||||18.48|12.75|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.48||||18.48|9.24|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.48||||18.48|12.75|14.04|3.7
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]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.48||||18.48|0|14.04|3.7
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]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.48||||18.48|12.75|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|18.48||||18.48|3.7|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.48||||18.48|12.75|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.48||||18.48|7.19|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.48||||18.48||14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.48||||18.48||14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.48||||18.48||14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.48||||18.48|12.75|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.48||||18.48|0|14.04|3.7
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]|18.48||||18.48|0|14.04|3.7
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.48||||18.48||14.04|3.7
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AARP [1000]|AARP [100000]|4560||||4560|216.98|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4560||||4560|141.66|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4560||||4560|3283.2|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4560||||4560|2280|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4560||||4560|2280|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4560||||4560|3465.6|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|4560||||4560|415.03|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4560||||4560|216.98|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4560||||4560|141.66|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|Self-pay|Self-pay|4560||||4560|912|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|TML [1980]|TML [198000]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4560||||4560|174.26|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4560||||4560|216.98|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|4560||||4560|216.98|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4560||||4560|216.98|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|4560||||4560|3146.4|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4560||||4560|0|3465.6|141.66
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]|4560||||4560|0|3465.6|141.66
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|4560||||4560|216.98|3465.6|141.66
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2753.25||||2753.25|424.05|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2753.25||||2753.25|232.12|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2753.25||||2753.25|401.86|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2753.25||||2753.25|1982.34|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2753.25||||2753.25|1376.63|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2753.25||||2753.25|1376.63|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2753.25||||2753.25|2092.47|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2753.25||||2753.25|1899.74|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|2753.25||||2753.25|873.89|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2753.25||||2753.25|424.05|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2753.25||||2753.25|232.12|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2753.25||||2753.25|1899.74|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2753.25||||2753.25|0|2092.47|232.12
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]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|Self-pay|Self-pay|2753.25||||2753.25|550.65|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|TML [1980]|TML [198000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2753.25||||2753.25|401.86|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2753.25||||2753.25|424.05|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|2753.25||||2753.25|424.05|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2753.25||||2753.25|424.05|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|2753.25||||2753.25|1899.74|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2753.25||||2753.25|0|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2753.25||||2753.25|232.12|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2753.25||||2753.25|401.86|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2753.25||||2753.25|1982.34|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2753.25||||2753.25|1376.63|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2753.25||||2753.25|1376.63|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2753.25||||2753.25|2092.47|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2753.25||||2753.25|1899.74|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|2753.25||||2753.25|873.89|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2753.25||||2753.25|232.12|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2753.25||||2753.25|1899.74|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2753.25||||2753.25|0|2092.47|232.12
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]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|Self-pay|Self-pay|2753.25||||2753.25|550.65|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|TML [1980]|TML [198000]|2753.25||||2753.25|1899.74|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2753.25||||2753.25|401.86|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2753.25||||2753.25|424.05|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|2753.25||||2753.25|1899.74|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2753.25||||2753.25|0|2092.47|232.12
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]|2753.25||||2753.25|0|2092.47|232.12
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|2753.25||||2753.25|424.05|2092.47|232.12
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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]|135.28||||135.28||102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AETNA [1015]|AETNA [101529]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMBETTER [2930]|AMBETTER [293000]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|135.28||||135.28|67.64|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|97.4|102.81|27.06
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]|135.28||||135.28|67.64|102.81|27.06
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]|135.28||||135.28|67.64|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|135.28||||135.28|102.81|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|135.28||||135.28|93.34|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA [1260]|CIGNA PPO [126025]|135.28||||135.28|54.11|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|135.28||||135.28||102.81|27.06
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]|135.28||||135.28|93.34|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|135.28||||135.28|67.64|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|135.28||||135.28|93.34|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28|93.34|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|Self-pay|Self-pay|135.28||||135.28|27.06|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|TML [1980]|TML [198000]|135.28||||135.28|93.34|102.81|27.06
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]|135.28||||135.28|52.65|102.81|27.06
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]|135.28||||135.28||102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNICARE [2040]|UNICARE [204000]|135.28||||135.28||102.81|27.06
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]|135.28||||135.28||102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WEB TPA [2115]|WEB TPA [211500]|135.28||||135.28|93.34|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
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]|135.28||||135.28|0|102.81|27.06
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WORKER'S COMP [2125]|TML WC [212537]|135.28||||135.28||102.81|27.06
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AARP [1000]|AARP [100000]|4270||||4270|216.98|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AETNA [1015]|AETNA [101529]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AMBETTER [2930]|AMBETTER [293000]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4270||||4270|141.66|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4270||||4270|181.99|3245.2|141.66
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]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4270||||4270|3074.4|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4270||||4270|2135|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4270||||4270|2135|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4270||||4270|3245.2|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4270||||4270|2946.3|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA [1260]|CIGNA PPO [126025]|4270||||4270|415.03|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4270||||4270|216.98|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4270||||4270|2946.3|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4270||||4270|141.66|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4270||||4270|2946.3|3245.2|141.66
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]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4270||||4270|0|3245.2|141.66
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]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4270||||4270|2946.3|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|Self-pay|Self-pay|4270||||4270|854|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|TML [1980]|TML [198000]|4270||||4270|2946.3|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4270||||4270|181.99|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4270||||4270|216.98|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UNICARE [2040]|UNICARE [204000]|4270||||4270|216.98|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4270||||4270|216.98|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|WEB TPA [2115]|WEB TPA [211500]|4270||||4270|2946.3|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4270||||4270|0|3245.2|141.66
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]|4270||||4270|0|3245.2|141.66
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|WORKER'S COMP [2125]|TML WC [212537]|4270||||4270|216.98|3245.2|141.66
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AARP [1000]|AARP [100000]|5578||||5578|371.44|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5578||||5578|232.12|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5578||||5578|4016.16|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5578||||5578|2789|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5578||||5578|2789|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5578||||5578|4239.28|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5578||||5578|873.89|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5578||||5578|371.44|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5578||||5578|232.12|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|Self-pay|Self-pay|5578||||5578|1115.6|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|TML [1980]|TML [198000]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5578||||5578|295.39|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5578||||5578|371.44|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5578||||5578|371.44|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5578||||5578|371.44|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5578||||5578|3848.82|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5578||||5578|0|4239.28|232.12
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]|5578||||5578|0|4239.28|232.12
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5578||||5578|371.44|4239.28|232.12
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|8540||||8540|382.56|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8540||||8540|299.17|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8540||||8540|6148.8|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8540||||8540|4270|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8540||||8540|4270|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8540||||8540|6490.4|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|8540||||8540|708.27|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8540||||8540|382.56|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8540||||8540|299.17|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|Self-pay|Self-pay|8540||||8540|1708|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|TML [1980]|TML [198000]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8540||||8540|301.77|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8540||||8540|382.56|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|8540||||8540|382.56|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8540||||8540|382.56|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|8540||||8540|5892.6|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8540||||8540|0|6490.4|299.17
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]|8540||||8540|0|6490.4|299.17
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|8540||||8540|382.56|6490.4|299.17
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AARP [1000]|AARP [100000]|11157||||11157|603.23|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11157||||11157|478.56|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11157||||11157|8033.04|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11157||||11157|5578.5|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11157||||11157|5578.5|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11157||||11157|8479.32|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|11157||||11157|1282.9|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11157||||11157|603.23|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11157||||11157|478.56|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|Self-pay|Self-pay|11157||||11157|2231.4|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|TML [1980]|TML [198000]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11157||||11157|401.86|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11157||||11157|603.23|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UNICARE [2040]|UNICARE [204000]|11157||||11157|603.23|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11157||||11157|603.23|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|11157||||11157|7698.33|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11157||||11157|0|8479.32|401.86
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|11157||||11157|603.23|8479.32|401.86
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMBETTER [2930]|AMBETTER [293000]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.63||||3.63|1.41|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.63||||3.63|1.82|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|2.61|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.63||||3.63|2.76|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.63||||3.63|2.5|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA PPO [126025]|3.63||||3.63|1.45|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.63||||3.63||2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.63||||3.63|2.5|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.63||||3.63|1.82|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|3.63||||3.63|0.73|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|TML [1980]|TML [198000]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.63||||3.63||2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNICARE [2040]|UNICARE [204000]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63||2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WEB TPA [2115]|WEB TPA [211500]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TML WC [212537]|3.63||||3.63||2.76|0.73
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|990||||990|495|752.4|13.39
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]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|990||||990|0|752.4|13.39
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]|990||||990|385.31|752.4|13.39
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]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|990||||990|13.39|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|990||||990|385.31|752.4|13.39
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]|990||||990|0|752.4|13.39
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]|990||||990|712.8|752.4|13.39
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]|990||||990|495|752.4|13.39
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]|990||||990|495|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|990||||990|752.4|752.4|13.39
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]|990||||990|385.31|752.4|13.39
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]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|990||||990|683.1|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|990||||990|396|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|990||||990|495|752.4|13.39
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]|990||||990|683.1|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|990||||990|13.39|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|990||||990|683.1|752.4|13.39
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]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|990||||990|0|752.4|13.39
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]|990||||990|385.31|752.4|13.39
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]|990||||990|0|752.4|13.39
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]|990||||990|0|752.4|13.39
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]|990||||990|385.31|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|990||||990|683.1|752.4|13.39
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]|990||||990|385.31|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|990||||990|198|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|990||||990|683.1|752.4|13.39
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]|990||||990|385.31|752.4|13.39
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]|990||||990|495|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|990||||990|495|752.4|13.39
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]|990||||990|495|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|990||||990|683.1|752.4|13.39
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]|990||||990|0|752.4|13.39
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]|990||||990|0|752.4|13.39
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|990||||990|495|752.4|13.39
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.88||||4.88||3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.88||||4.88|2.44|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.88||||4.88|1.9|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.88||||4.88|3.51|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.88||||4.88|2.44|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.88||||4.88|2.44|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.88||||4.88|3.71|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.88||||4.88|3.37|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.88||||4.88|1.95|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.88||||4.88||3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.88||||4.88|3.37|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.88||||4.88|2.44|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.88||||4.88|3.37|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.88||||4.88|3.37|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|4.88||||4.88|0.98|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.88||||4.88|3.37|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.88||||4.88|1.9|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.88||||4.88||3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.88||||4.88||3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.88||||4.88||3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.88||||4.88|3.37|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.88||||4.88|0|3.71|0.98
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]|4.88||||4.88|0|3.71|0.98
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.88||||4.88||3.71|0.98
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.82||||10.82||8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.82||||10.82|5.41|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.82||||10.82|4.21|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.82||||10.82|7.79|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.82||||10.82|5.41|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.82||||10.82|5.41|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.82||||10.82|8.22|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.82||||10.82|7.47|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.82||||10.82|4.33|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.82||||10.82||8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.82||||10.82|7.47|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.82||||10.82|5.41|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.82||||10.82|7.47|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.82||||10.82|7.47|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|10.82||||10.82|2.16|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.82||||10.82|7.47|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.82||||10.82|4.21|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.82||||10.82||8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.82||||10.82||8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.82||||10.82||8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.82||||10.82|7.47|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.82||||10.82|0|8.22|2.16
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]|10.82||||10.82|0|8.22|2.16
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.82||||10.82||8.22|2.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|79.07||||79.07|39.54|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.07||||79.07|30.77|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.07||||79.07|1.16|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.07||||79.07|30.77|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
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]|79.07||||79.07|56.93|60.09|1.16
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]|79.07||||79.07|39.54|60.09|1.16
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]|79.07||||79.07|39.54|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.07||||79.07|60.09|60.09|1.16
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]|79.07||||79.07|30.77|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.07||||79.07|54.56|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|79.07||||79.07|31.63|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.07||||79.07|39.54|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.07||||79.07|54.56|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.07||||79.07|1.16|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.07||||79.07|54.56|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.07||||79.07|0|60.09|1.16
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]|79.07||||79.07|30.77|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.07||||79.07|0|60.09|1.16
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]|79.07||||79.07|30.77|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.07||||79.07|54.56|60.09|1.16
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]|79.07||||79.07|30.77|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|79.07||||79.07|15.81|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|79.07||||79.07|54.56|60.09|1.16
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]|79.07||||79.07|30.77|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.07||||79.07|39.54|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|79.07||||79.07|39.54|60.09|1.16
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]|79.07||||79.07|39.54|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|79.07||||79.07|54.56|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
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]|79.07||||79.07|0|60.09|1.16
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|79.07||||79.07|39.54|60.09|1.16
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AARP [1000]|AARP [100000]|2616||||2616|1152|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AETNA [1015]|AETNA [101529]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AMBETTER [2930]|AMBETTER [293000]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2616||||2616|1018.15|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2616||||2616|808.56|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2616||||2616|1018.15|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
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]|2616||||2616|1883.52|1988.16|523.2
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]|2616||||2616|1308|1988.16|523.2
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]|2616||||2616|1308|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2616||||2616|1988.16|1988.16|523.2
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]|2616||||2616|1018.15|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2616||||2616|1674.24|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|CIGNA [1260]|CIGNA PPO [126025]|2616||||2616|1930|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2616||||2616|1152|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2616||||2616|1674.24|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2616||||2616|808.56|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2616||||2616|1674.24|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2616||||2616|0|1988.16|523.2
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]|2616||||2616|1018.15|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2616||||2616|0|1988.16|523.2
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]|2616||||2616|1018.15|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2616||||2616|1674.24|1988.16|523.2
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]|2616||||2616|1018.15|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|Self-pay|Self-pay|2616||||2616|523.2|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|TML [1980]|TML [198000]|2616||||2616|1674.24|1988.16|523.2
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]|2616||||2616|1018.15|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2616||||2616|1152|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UNICARE [2040]|UNICARE [204000]|2616||||2616|1152|1988.16|523.2
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]|2616||||2616|1152|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|WEB TPA [2115]|WEB TPA [211500]|2616||||2616|1674.24|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
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]|2616||||2616|0|1988.16|523.2
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|WORKER'S COMP [2125]|TML WC [212537]|2616||||2616|1152|1988.16|523.2
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AARP [1000]|AARP [100000]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA [1015]|AETNA [101529]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMBETTER [2930]|AMBETTER [293000]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1959.6||||1959.6|808.56|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1959.6||||1959.6|1410.91|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1959.6||||1959.6|979.8|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1959.6||||1959.6|979.8|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1959.6||||1959.6|1489.3|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA [1260]|CIGNA PPO [126025]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1959.6||||1959.6|808.56|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|Self-pay|Self-pay|1959.6||||1959.6|391.92|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|TML [1980]|TML [198000]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1959.6||||1959.6|762.68|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNICARE [2040]|UNICARE [204000]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1959.6||||1959.6||1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WEB TPA [2115]|WEB TPA [211500]|1959.6||||1959.6|1254.14|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1959.6||||1959.6|0|1489.3|391.92
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]|1959.6||||1959.6|0|1489.3|391.92
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WORKER'S COMP [2125]|TML WC [212537]|1959.6||||1959.6||1489.3|391.92
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AARP [1000]|AARP [100000]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AETNA [1015]|AETNA [101529]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AMBETTER [2930]|AMBETTER [293000]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3710||||3710|1829.1|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3710||||3710|2671.2|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3710||||3710|1855|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3710||||3710|1855|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3710||||3710|2819.6|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA [1260]|CIGNA PPO [126025]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3710||||3710|1829.1|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|Self-pay|Self-pay|3710||||3710|742|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|TML [1980]|TML [198000]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3710||||3710|1443.93|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UNICARE [2040]|UNICARE [204000]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3710||||3710||2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|WEB TPA [2115]|WEB TPA [211500]|3710||||3710|2374.4|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3710||||3710|0|2819.6|742
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]|3710||||3710|0|2819.6|742
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|WORKER'S COMP [2125]|TML WC [212537]|3710||||3710||2819.6|742
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AARP [1000]|AARP [100000]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AETNA [1015]|AETNA [101529]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AMBETTER [2930]|AMBETTER [293000]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|940||||940|275.08|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|940||||940|676.8|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|940||||940|470|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|940||||940|470|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|940||||940|714.4|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA [1260]|CIGNA PPO [126025]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|940||||940|275.08|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|Self-pay|Self-pay|940||||940|188|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|TML [1980]|TML [198000]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|940||||940|365.85|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UNICARE [2040]|UNICARE [204000]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|940||||940||714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WEB TPA [2115]|WEB TPA [211500]|940||||940|601.6|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|940||||940|0|714.4|188
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WORKER'S COMP [2125]|TML WC [212537]|940||||940||714.4|188
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AARP [1000]|AARP [100000]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AETNA [1015]|AETNA [101529]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AMBETTER [2930]|AMBETTER [293000]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|613||||613|275.08|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|613||||613|441.36|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|613||||613|306.5|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|613||||613|306.5|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|613||||613|465.88|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|CIGNA [1260]|CIGNA PPO [126025]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|613||||613|275.08|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|Self-pay|Self-pay|613||||613|122.6|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|TML [1980]|TML [198000]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|613||||613|238.58|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|UNICARE [2040]|UNICARE [204000]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|613||||613||465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|WEB TPA [2115]|WEB TPA [211500]|613||||613|392.32|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|613||||613|0|465.88|122.6
36031502|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOTOMY TUBE CHANGE|1|WORKER'S COMP [2125]|TML WC [212537]|613||||613||465.88|122.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AARP [1000]|AARP [100000]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AETNA [1015]|AETNA [101529]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AMBETTER [2930]|AMBETTER [293000]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7918||||7918|3557.31|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7918||||7918|5700.96|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7918||||7918|3959|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7918||||7918|3959|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7918||||7918|6017.68|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|CIGNA [1260]|CIGNA PPO [126025]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7918||||7918|3557.31|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|Self-pay|Self-pay|7918||||7918|1583.6|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|TML [1980]|TML [198000]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7918||||7918|3081.69|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|UNICARE [2040]|UNICARE [204000]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7918||||7918||6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|WEB TPA [2115]|WEB TPA [211500]|7918||||7918|5067.52|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7918||||7918|0|6017.68|1583.6
36031600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE|1|WORKER'S COMP [2125]|TML WC [212537]|7918||||7918||6017.68|1583.6
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AARP [1000]|AARP [100000]|3671.79||||3671.79|1501|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AETNA [1015]|AETNA [101529]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AMBETTER [2930]|AMBETTER [293000]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.79||||3671.79|1945.31|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.79||||3671.79|2643.69|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.79||||3671.79|1835.9|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.79||||3671.79|1835.9|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.79||||3671.79|2790.56|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA [1260]|CIGNA PPO [126025]|3671.79||||3671.79|1930|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.79||||3671.79|1501|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.79||||3671.79|1945.31|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|Self-pay|Self-pay|3671.79||||3671.79|734.36|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|TML [1980]|TML [198000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.79||||3671.79|1429.06|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.79||||3671.79|1501|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UNICARE [2040]|UNICARE [204000]|3671.79||||3671.79|1501|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.79||||3671.79|1501|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WEB TPA [2115]|WEB TPA [211500]|3671.79||||3671.79|2349.95|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.79||||3671.79|0|2790.56|734.36
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WORKER'S COMP [2125]|TML WC [212537]|3671.79||||3671.79|1501|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AARP [1000]|AARP [100000]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AETNA [1015]|AETNA [101529]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AMBETTER [2930]|AMBETTER [293000]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.79||||3671.79|1945.31|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.79||||3671.79|2643.69|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.79||||3671.79|1835.9|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.79||||3671.79|1835.9|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.79||||3671.79|2790.56|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA [1260]|CIGNA PPO [126025]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.79||||3671.79|1945.31|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|Self-pay|Self-pay|3671.79||||3671.79|734.36|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|TML [1980]|TML [198000]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.79||||3671.79|1429.06|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UNICARE [2040]|UNICARE [204000]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.79||||3671.79||2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WEB TPA [2115]|WEB TPA [211500]|3671.79||||3671.79|2349.95|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.79||||3671.79|0|2790.56|734.36
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WORKER'S COMP [2125]|TML WC [212537]|3671.79||||3671.79||2790.56|734.36
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AARP [1000]|AARP [100000]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA [1015]|AETNA [101529]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMBETTER [2930]|AMBETTER [293000]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3390.2||||3390.2|1945.31|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3390.2||||3390.2|2440.94|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3390.2||||3390.2|1695.1|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3390.2||||3390.2|1695.1|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3390.2||||3390.2|2576.55|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA [1260]|CIGNA PPO [126025]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3390.2||||3390.2|1945.31|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|Self-pay|Self-pay|3390.2||||3390.2|678.04|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|TML [1980]|TML [198000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3390.2||||3390.2|1319.47|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNICARE [2040]|UNICARE [204000]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3390.2||||3390.2||2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WEB TPA [2115]|WEB TPA [211500]|3390.2||||3390.2|2169.73|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3390.2||||3390.2|0|2576.55|678.04
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WORKER'S COMP [2125]|TML WC [212537]|3390.2||||3390.2||2576.55|678.04
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AARP [1000]|AARP [100000]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AETNA [1015]|AETNA [101529]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AMBETTER [2930]|AMBETTER [293000]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.79||||3671.79|4027.43|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.79||||3671.79|2643.69|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.79||||3671.79|1835.9|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.79||||3671.79|1835.9|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.79||||3671.79|2790.56|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|CIGNA [1260]|CIGNA PPO [126025]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.79||||3671.79|4027.43|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|Self-pay|Self-pay|3671.79||||3671.79|734.36|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|TML [1980]|TML [198000]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.79||||3671.79|1429.06|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|UNICARE [2040]|UNICARE [204000]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.79||||3671.79||4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|WEB TPA [2115]|WEB TPA [211500]|3671.79||||3671.79|2349.95|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.79||||3671.79|0|4027.43|734.36
36031629|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/TRANSBRONCH ASP BX|1|WORKER'S COMP [2125]|TML WC [212537]|3671.79||||3671.79||4027.43|734.36
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AARP [1000]|AARP [100000]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AETNA [1015]|AETNA [101529]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AMBETTER [2930]|AMBETTER [293000]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9525.6||||9525.6|4027.43|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9525.6||||9525.6|6858.43|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9525.6||||9525.6|4762.8|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9525.6||||9525.6|4762.8|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9525.6||||9525.6|7239.46|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|CIGNA [1260]|CIGNA PPO [126025]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9525.6||||9525.6|4027.43|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|Self-pay|Self-pay|9525.6||||9525.6|1905.12|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|TML [1980]|TML [198000]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9525.6||||9525.6|3707.36|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|UNICARE [2040]|UNICARE [204000]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9525.6||||9525.6||7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|WEB TPA [2115]|WEB TPA [211500]|9525.6||||9525.6|6096.38|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9525.6||||9525.6|0|7239.46|1905.12
36031641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY DESTROY TUMOR/STENOS|1|WORKER'S COMP [2125]|TML WC [212537]|9525.6||||9525.6||7239.46|1905.12
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AARP [1000]|AARP [100000]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AETNA [1015]|AETNA [101529]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AMBETTER [2930]|AMBETTER [293000]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3390.2||||3390.2|1945.31|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3390.2||||3390.2|2440.94|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3390.2||||3390.2|1695.1|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3390.2||||3390.2|1695.1|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3390.2||||3390.2|2576.55|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|CIGNA [1260]|CIGNA PPO [126025]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3390.2||||3390.2|1945.31|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|Self-pay|Self-pay|3390.2||||3390.2|678.04|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|TML [1980]|TML [198000]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3390.2||||3390.2|1319.47|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|UNICARE [2040]|UNICARE [204000]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3390.2||||3390.2||2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|WEB TPA [2115]|WEB TPA [211500]|3390.2||||3390.2|2169.73|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3390.2||||3390.2|0|2576.55|678.04
36031645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP INITIAL|1|WORKER'S COMP [2125]|TML WC [212537]|3390.2||||3390.2||2576.55|678.04
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AARP [1000]|AARP [100000]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AETNA [1015]|AETNA [101529]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AMBETTER [2930]|AMBETTER [293000]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3671.79||||3671.79|489.46|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3671.79||||3671.79|2643.69|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3671.79||||3671.79|1835.9|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3671.79||||3671.79|1835.9|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3671.79||||3671.79|2790.56|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|CIGNA [1260]|CIGNA PPO [126025]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3671.79||||3671.79|489.46|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|Self-pay|Self-pay|3671.79||||3671.79|734.36|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|TML [1980]|TML [198000]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3671.79||||3671.79|1429.06|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|UNICARE [2040]|UNICARE [204000]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3671.79||||3671.79||2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|WEB TPA [2115]|WEB TPA [211500]|3671.79||||3671.79|2349.95|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3671.79||||3671.79|0|2790.56|489.46
36031646|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCH W/TRANSBRNCH ASP SUBSEQUNT|1|WORKER'S COMP [2125]|TML WC [212537]|3671.79||||3671.79||2790.56|489.46
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AARP [1000]|AARP [100000]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AETNA [1015]|AETNA [101529]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AMBETTER [2930]|AMBETTER [293000]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|544||||544|244.24|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|544||||544|391.68|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|544||||544|272|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|544||||544|272|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|544||||544|413.44|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|CIGNA [1260]|CIGNA PPO [126025]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|544||||544|244.24|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|Self-pay|Self-pay|544||||544|108.8|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|TML [1980]|TML [198000]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|544||||544|211.72|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|UNICARE [2040]|UNICARE [204000]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|544||||544||413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|WEB TPA [2115]|WEB TPA [211500]|544||||544|348.16|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|544||||544|0|413.44|108.8
36031720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION CATHETER NASOTRACHEAL|1|WORKER'S COMP [2125]|TML WC [212537]|544||||544||413.44|108.8
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AARP [1000]|AARP [100000]|32568.65||||32568.65|18283|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AETNA [1015]|AETNA [101529]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AMBETTER [2930]|AMBETTER [293000]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|32568.65||||32568.65|13520.2|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32568.65||||32568.65|23449.43|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32568.65||||32568.65|16284.33|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32568.65||||32568.65|16284.33|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|32568.65||||32568.65|24752.17|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|CIGNA [1260]|CIGNA PPO [126025]|32568.65||||32568.65|2012|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|32568.65||||32568.65|18283|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|32568.65||||32568.65|13520.2|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|Self-pay|Self-pay|32568.65||||32568.65|6513.73|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|TML [1980]|TML [198000]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32568.65||||32568.65|12675.72|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32568.65||||32568.65|18283|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|UNICARE [2040]|UNICARE [204000]|32568.65||||32568.65|18283|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32568.65||||32568.65|18283|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|WEB TPA [2115]|WEB TPA [211500]|32568.65||||32568.65|20843.94|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32568.65||||32568.65|0|24752.17|2012
36033208|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT PACEMAKER ATRIAL & VENTRICULAR|1|WORKER'S COMP [2125]|TML WC [212537]|32568.65||||32568.65|18283|24752.17|2012
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AARP [1000]|AARP [100000]|90||||90|1.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA [1015]|AETNA [101529]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMBETTER [2930]|AMBETTER [293000]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90||||90|3.9|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90||||90|64.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90||||90|45|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90||||90|45|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90||||90|68.4|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA [1260]|CIGNA PPO [126025]|90||||90|6.45|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90||||90|1.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90||||90|3.9|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|Self-pay|Self-pay|90||||90|18|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|TML [1980]|TML [198000]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90||||90|1.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNICARE [2040]|UNICARE [204000]|90||||90|1.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90||||90|1.8|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WEB TPA [2115]|WEB TPA [211500]|90||||90|62.1|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90||||90|0|68.4|1.8
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WORKER'S COMP [2125]|TML WC [212537]|90||||90|1.8|68.4|1.8
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AARP [1000]|AARP [100000]|37||||37|1.72|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AETNA [1015]|AETNA [101529]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AMBETTER [2930]|AMBETTER [293000]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37||||37|18.5|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|26.64|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|18.5|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|18.5|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37||||37|28.12|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA [1260]|CIGNA PPO [126025]|37||||37|6.16|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37||||37|1.72|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37||||37|18.5|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|Self-pay|Self-pay|37||||37|7.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|TML [1980]|TML [198000]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37|14.4|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37|1.72|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UNICARE [2040]|UNICARE [204000]|37||||37|1.72|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37|1.72|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WEB TPA [2115]|WEB TPA [211500]|37||||37|25.53|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37||||37|0|28.12|1.72
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WORKER'S COMP [2125]|TML WC [212537]|37||||37|1.72|28.12|1.72
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AARP [1000]|AARP [100000]|4409||||4409|1152|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AETNA [1015]|AETNA [101529]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AMBETTER [2930]|AMBETTER [293000]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4409||||4409|3720.16|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4409||||4409|1715.98|3720.16|881.8
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]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4409||||4409|3174.48|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4409||||4409|2204.5|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4409||||4409|2204.5|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4409||||4409|3350.84|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4409||||4409|2821.76|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA [1260]|CIGNA PPO [126025]|4409||||4409|1930|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4409||||4409|1152|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4409||||4409|2821.76|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4409||||4409|3720.16|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4409||||4409|2821.76|3720.16|881.8
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]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4409||||4409|0|3720.16|881.8
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]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4409||||4409|2821.76|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|Self-pay|Self-pay|4409||||4409|881.8|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|TML [1980]|TML [198000]|4409||||4409|2821.76|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4409||||4409|1715.98|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4409||||4409|1152|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UNICARE [2040]|UNICARE [204000]|4409||||4409|1152|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4409||||4409|1152|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|WEB TPA [2115]|WEB TPA [211500]|4409||||4409|2821.76|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4409||||4409|0|3720.16|881.8
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]|4409||||4409|0|3720.16|881.8
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|WORKER'S COMP [2125]|TML WC [212537]|4409||||4409|1152|3720.16|881.8
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AARP [1000]|AARP [100000]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AETNA [1015]|AETNA [101529]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMBETTER [2930]|AMBETTER [293000]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7477||||7477|3720.16|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7477||||7477|5383.44|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7477||||7477|3738.5|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7477||||7477|3738.5|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7477||||7477|5682.52|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|CIGNA [1260]|CIGNA PPO [126025]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7477||||7477|3720.16|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|Self-pay|Self-pay|7477||||7477|1495.4|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|TML [1980]|TML [198000]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7477||||7477|2910.05|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UNICARE [2040]|UNICARE [204000]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7477||||7477||5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WEB TPA [2115]|WEB TPA [211500]|7477||||7477|4785.28|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7477||||7477|0|5682.52|1495.4
36036558|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS TNNL W/O SUBQ PORT =>5 YRS|1|WORKER'S COMP [2125]|TML WC [212537]|7477||||7477||5682.52|1495.4
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AARP [1000]|AARP [100000]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AETNA [1015]|AETNA [101529]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AMBETTER [2930]|AMBETTER [293000]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6158.25||||6158.25|704.11|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6158.25||||6158.25|4433.94|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6158.25||||6158.25|3079.13|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6158.25||||6158.25|3079.13|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6158.25||||6158.25|4680.27|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA PPO [126025]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6158.25||||6158.25|704.11|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|Self-pay|Self-pay|6158.25||||6158.25|1231.65|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|TML [1980]|TML [198000]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6158.25||||6158.25|2396.79|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|UNICARE [2040]|UNICARE [204000]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6158.25||||6158.25||4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|WEB TPA [2115]|WEB TPA [211500]|6158.25||||6158.25|3941.28|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6158.25||||6158.25|0|4680.27|704.11
36036575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR CV CATH W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TML WC [212537]|6158.25||||6158.25||4680.27|704.11
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AARP [1000]|AARP [100000]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AETNA [1015]|AETNA [101529]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMBETTER [2930]|AMBETTER [293000]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8280||||8280|3720.16|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8280||||8280|5961.6|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8280||||8280|4140|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8280||||8280|4140|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8280||||8280|6292.8|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|CIGNA [1260]|CIGNA PPO [126025]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8280||||8280|3720.16|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|Self-pay|Self-pay|8280||||8280|1656|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|TML [1980]|TML [198000]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8280||||8280|3222.58|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UNICARE [2040]|UNICARE [204000]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8280||||8280||6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WEB TPA [2115]|WEB TPA [211500]|8280||||8280|5299.2|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8280||||8280|0|6292.8|1656
36036581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE COMPL TUN CVC W/O SUBQ PORT/PUMP|1|WORKER'S COMP [2125]|TML WC [212537]|8280||||8280||6292.8|1656
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AARP [1000]|AARP [100000]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AETNA [1015]|AETNA [101529]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AMBETTER [2930]|AMBETTER [293000]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2675||||2675|704.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2675||||2675|1041.11|2033|535
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]|2675||||2675|0|2033|535
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]|2675||||2675|1926|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2675||||2675|1337.5|2033|535
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]|2675||||2675|1337.5|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2675||||2675|2033|2033|535
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]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2675||||2675|1712|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA [1260]|CIGNA PPO [126025]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2675||||2675|1712|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2675||||2675|704.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2675||||2675|1712|2033|535
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]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2675||||2675|0|2033|535
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]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2675||||2675|1712|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|Self-pay|Self-pay|2675||||2675|535|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|TML [1980]|TML [198000]|2675||||2675|1712|2033|535
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]|2675||||2675|1041.11|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UNICARE [2040]|UNICARE [204000]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2675||||2675||2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|WEB TPA [2115]|WEB TPA [211500]|2675||||2675|1712|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2675||||2675|0|2033|535
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]|2675||||2675|0|2033|535
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|WORKER'S COMP [2125]|TML WC [212537]|2675||||2675||2033|535
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AARP [1000]|AARP [100000]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA [1015]|AETNA [101529]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMBETTER [2930]|AMBETTER [293000]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|71.25||||71.25|145.54|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.25||||71.25|51.3|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|71.25||||71.25|54.15|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA [1260]|CIGNA PPO [126025]|71.25||||71.25|71.25|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|71.25||||71.25|145.54|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|Self-pay|Self-pay|71.25||||71.25|14.25|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|TML [1980]|TML [198000]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.25||||71.25|27.73|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNICARE [2040]|UNICARE [204000]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.25||||71.25|35.63|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WEB TPA [2115]|WEB TPA [211500]|71.25||||71.25|49.16|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.25||||71.25|0|145.54|14.25
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WORKER'S COMP [2125]|TML WC [212537]|71.25||||71.25|35.63|145.54|14.25
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AARP [1000]|AARP [100000]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AETNA [1015]|AETNA [101529]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AMBETTER [2930]|AMBETTER [293000]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13802||||13802|6201.48|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13802||||13802|9937.44|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13802||||13802|6901|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13802||||13802|6901|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13802||||13802|10489.52|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|CIGNA [1260]|CIGNA PPO [126025]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13802||||13802|6201.48|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|Self-pay|Self-pay|13802||||13802|2760.4|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|TML [1980]|TML [198000]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13802||||13802|5371.74|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|UNICARE [2040]|UNICARE [204000]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13802||||13802||10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|WEB TPA [2115]|WEB TPA [211500]|13802||||13802|8833.28|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13802||||13802|0|10489.52|2760.4
36037191|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT IVC FILTR W/ACCES/IMAGE|1|WORKER'S COMP [2125]|TML WC [212537]|13802||||13802||10489.52|2760.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AARP [1000]|AARP [100000]|4702||||4702|1501|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AETNA [1015]|AETNA [101529]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AMBETTER [2930]|AMBETTER [293000]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4702||||4702|2112.53|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4702||||4702|3385.44|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4702||||4702|2351|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4702||||4702|2351|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4702||||4702|3573.52|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA [1260]|CIGNA PPO [126025]|4702||||4702|1985|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4702||||4702|1501|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4702||||4702|2112.53|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|Self-pay|Self-pay|4702||||4702|940.4|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|TML [1980]|TML [198000]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4702||||4702|1830.02|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4702||||4702|1501|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UNICARE [2040]|UNICARE [204000]|4702||||4702|1501|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4702||||4702|1501|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WEB TPA [2115]|WEB TPA [211500]|4702||||4702|3009.28|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4702||||4702|0|3573.52|940.4
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WORKER'S COMP [2125]|TML WC [212537]|4702||||4702|1501|3573.52|940.4
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AARP [1000]|AARP [100000]|1753.75||||1753.75||1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AETNA [1015]|AETNA [101529]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AMBETTER [2930]|AMBETTER [293000]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1753.75||||1753.75|682.56|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1753.75||||1753.75|351.29|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1753.75||||1753.75|682.56|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
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]|1753.75||||1753.75|1262.7|1332.85|350.75
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]|1753.75||||1753.75|876.88|1332.85|350.75
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]|1753.75||||1753.75|876.88|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1753.75||||1753.75|1332.85|1332.85|350.75
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]|1753.75||||1753.75|682.56|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1753.75||||1753.75|1122.4|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|CIGNA [1260]|CIGNA PPO [126025]|1753.75||||1753.75||1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1753.75||||1753.75||1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1753.75||||1753.75|1122.4|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1753.75||||1753.75|351.29|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1753.75||||1753.75|1122.4|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1753.75||||1753.75|0|1332.85|350.75
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]|1753.75||||1753.75|682.56|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1753.75||||1753.75|0|1332.85|350.75
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]|1753.75||||1753.75|682.56|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1753.75||||1753.75|1122.4|1332.85|350.75
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]|1753.75||||1753.75|682.56|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|Self-pay|Self-pay|1753.75||||1753.75|350.75|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|TML [1980]|TML [198000]|1753.75||||1753.75|1122.4|1332.85|350.75
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]|1753.75||||1753.75|682.56|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1753.75||||1753.75||1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UNICARE [2040]|UNICARE [204000]|1753.75||||1753.75||1332.85|350.75
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]|1753.75||||1753.75||1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|WEB TPA [2115]|WEB TPA [211500]|1753.75||||1753.75|1122.4|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
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]|1753.75||||1753.75|0|1332.85|350.75
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|WORKER'S COMP [2125]|TML WC [212537]|1753.75||||1753.75||1332.85|350.75
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]|92.4||||92.4|46.2|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|0.21|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|66.53|70.22|0.21
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]|92.4||||92.4|46.2|70.22|0.21
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]|92.4||||92.4|46.2|70.22|0.21
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 TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|46.2|70.22|0.21
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]|92.4||||92.4|63.76|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|0.21|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|63.76|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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|92.4||||92.4|18.48|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|0.21
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]|92.4||||92.4|35.96|70.22|0.21
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]|92.4||||92.4|46.2|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|46.2|70.22|0.21
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]|92.4||||92.4|46.2|70.22|0.21
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|92.4||||92.4|0|70.22|0.21
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]|TML WC [212537]|92.4||||92.4|46.2|70.22|0.21
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AARP [1000]|AARP [100000]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AETNA [1015]|AETNA [101529]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AMBETTER [2930]|AMBETTER [293000]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7709||||7709|4138.43|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7709||||7709|3000.34|5858.84|1541.8
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]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7709||||7709|5550.48|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7709||||7709|3854.5|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7709||||7709|3854.5|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7709||||7709|5858.84|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7709||||7709|4933.76|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA [1260]|CIGNA PPO [126025]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7709||||7709|4933.76|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7709||||7709|4138.43|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7709||||7709|4933.76|5858.84|1541.8
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]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7709||||7709|0|5858.84|1541.8
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]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7709||||7709|4933.76|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|Self-pay|Self-pay|7709||||7709|1541.8|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|TML [1980]|TML [198000]|7709||||7709|4933.76|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7709||||7709|3000.34|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UNICARE [2040]|UNICARE [204000]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7709||||7709||5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|WEB TPA [2115]|WEB TPA [211500]|7709||||7709|4933.76|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7709||||7709|0|5858.84|1541.8
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]|7709||||7709|0|5858.84|1541.8
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|WORKER'S COMP [2125]|TML WC [212537]|7709||||7709||5858.84|1541.8
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AARP [1000]|AARP [100000]|2141||||2141|1501|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AETNA [1015]|AETNA [101529]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AMBETTER [2930]|AMBETTER [293000]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2141||||2141|1052.48|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2141||||2141|1541.52|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2141||||2141|1070.5|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2141||||2141|1070.5|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2141||||2141|1627.16|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA [1260]|CIGNA PPO [126025]|2141||||2141|1930|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2141||||2141|1501|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2141||||2141|1052.48|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|Self-pay|Self-pay|2141||||2141|428.2|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|TML [1980]|TML [198000]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2141||||2141|833.28|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2141||||2141|1501|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UNICARE [2040]|UNICARE [204000]|2141||||2141|1501|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2141||||2141|1501|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WEB TPA [2115]|WEB TPA [211500]|2141||||2141|1370.24|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2141||||2141|0|1930|428.2
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WORKER'S COMP [2125]|TML WC [212537]|2141||||2141|1501|1930|428.2
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AARP [1000]|AARP [100000]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AETNA [1015]|AETNA [101529]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AMBETTER [2930]|AMBETTER [293000]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9429||||9429|1829.1|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9429||||9429|6788.88|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9429||||9429|4714.5|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9429||||9429|4714.5|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9429||||9429|7166.04|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA [1260]|CIGNA PPO [126025]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9429||||9429|1829.1|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|Self-pay|Self-pay|9429||||9429|1885.8|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|TML [1980]|TML [198000]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9429||||9429|3669.77|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UNICARE [2040]|UNICARE [204000]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9429||||9429||7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|WEB TPA [2115]|WEB TPA [211500]|9429||||9429|6034.56|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9429||||9429|0|7166.04|1829.1
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]|9429||||9429|0|7166.04|1829.1
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|WORKER'S COMP [2125]|TML WC [212537]|9429||||9429||7166.04|1829.1
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AARP [1000]|AARP [100000]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AETNA [1015]|AETNA [101529]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AMBETTER [2930]|AMBETTER [293000]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4805||||4805|2112.53|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4805||||4805|3459.6|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4805||||4805|2402.5|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4805||||4805|2402.5|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4805||||4805|3651.8|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|CIGNA [1260]|CIGNA PPO [126025]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4805||||4805|2112.53|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|Self-pay|Self-pay|4805||||4805|961|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|TML [1980]|TML [198000]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4805||||4805|1870.11|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|UNICARE [2040]|UNICARE [204000]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4805||||4805||3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|WEB TPA [2115]|WEB TPA [211500]|4805||||4805|3075.2|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4805||||4805|0|3651.8|961
36049446|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONVRT GASTROTUBE TO GASTRO JE|1|WORKER'S COMP [2125]|TML WC [212537]|4805||||4805||3651.8|961
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AARP [1000]|AARP [100000]|1705.45||||1705.45|521|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AETNA [1015]|AETNA [101529]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AMBETTER [2930]|AMBETTER [293000]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1705.45||||1705.45|299.17|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1705.45||||1705.45|1227.92|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1705.45||||1705.45|852.73|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1705.45||||1705.45|852.73|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1705.45||||1705.45|1296.14|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA [1260]|CIGNA PPO [126025]|1705.45||||1705.45|717|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1705.45||||1705.45|521|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1705.45||||1705.45|299.17|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|Self-pay|Self-pay|1705.45||||1705.45|341.09|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|TML [1980]|TML [198000]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1705.45||||1705.45|663.76|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1705.45||||1705.45|521|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UNICARE [2040]|UNICARE [204000]|1705.45||||1705.45|521|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1705.45||||1705.45|521|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|WEB TPA [2115]|WEB TPA [211500]|1705.45||||1705.45|1091.49|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1705.45||||1705.45|0|1296.14|299.17
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]|1705.45||||1705.45|0|1296.14|299.17
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|WORKER'S COMP [2125]|TML WC [212537]|1705.45||||1705.45|521|1296.14|299.17
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|21.32||||21.32||16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.32||||21.32|10.66|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.32||||21.32|8.3|16.2|4.26
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]|21.32||||21.32|0|16.2|4.26
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]|21.32||||21.32|15.35|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.32||||21.32|10.66|16.2|4.26
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]|21.32||||21.32|10.66|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.32||||21.32|16.2|16.2|4.26
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]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.32||||21.32|14.71|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|21.32||||21.32|8.53|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.32||||21.32||16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.32||||21.32|14.71|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.32||||21.32|10.66|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.32||||21.32|14.71|16.2|4.26
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]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.32||||21.32|0|16.2|4.26
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]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.32||||21.32|14.71|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|21.32||||21.32|4.26|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|21.32||||21.32|14.71|16.2|4.26
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]|21.32||||21.32|8.3|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.32||||21.32||16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|21.32||||21.32||16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.32||||21.32||16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|21.32||||21.32|14.71|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.32||||21.32|0|16.2|4.26
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]|21.32||||21.32|0|16.2|4.26
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|21.32||||21.32||16.2|4.26
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.63||||19.63||14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|19.63||||19.63|9.82|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|19.63||||19.63|7.64|14.92|3.93
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]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.63||||19.63|14.13|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.63||||19.63|9.82|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.63||||19.63|9.82|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|19.63||||19.63|14.92|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|19.63||||19.63|13.54|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|19.63||||19.63|7.85|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|19.63||||19.63||14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.63||||19.63|13.54|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|19.63||||19.63|9.82|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|19.63||||19.63|13.54|14.92|3.93
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]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.63||||19.63|0|14.92|3.93
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]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.63||||19.63|13.54|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|Self-pay|Self-pay|19.63||||19.63|3.93|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|19.63||||19.63|13.54|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.63||||19.63|7.64|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.63||||19.63||14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|19.63||||19.63||14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.63||||19.63||14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|19.63||||19.63|13.54|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.63||||19.63|0|14.92|3.93
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]|19.63||||19.63|0|14.92|3.93
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|19.63||||19.63||14.92|3.93
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AARP [1000]|AARP [100000]|237.26||||237.26||180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AETNA [1015]|AETNA [101529]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AMBETTER [2930]|AMBETTER [293000]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|237.26||||237.26|118.63|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|170.83|180.32|47.45
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]|237.26||||237.26|118.63|180.32|47.45
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]|237.26||||237.26|118.63|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|237.26||||237.26|180.32|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|237.26||||237.26|163.71|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|CIGNA [1260]|CIGNA PPO [126025]|237.26||||237.26|94.9|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|237.26||||237.26||180.32|47.45
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]|237.26||||237.26|163.71|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|237.26||||237.26|118.63|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|237.26||||237.26|163.71|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26|163.71|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|Self-pay|Self-pay|237.26||||237.26|47.45|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|TML [1980]|TML [198000]|237.26||||237.26|163.71|180.32|47.45
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]|237.26||||237.26|92.34|180.32|47.45
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]|237.26||||237.26||180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UNICARE [2040]|UNICARE [204000]|237.26||||237.26||180.32|47.45
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]|237.26||||237.26||180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|WEB TPA [2115]|WEB TPA [211500]|237.26||||237.26|163.71|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
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]|237.26||||237.26|0|180.32|47.45
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|WORKER'S COMP [2125]|TML WC [212537]|237.26||||237.26||180.32|47.45
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47||1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.47||||1.47|0.74|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.47||||1.47|0.57|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|1.06|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.74|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.74|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.47||||1.47|1.12|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.47||||1.47|1.01|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.47||||1.47|0.59|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.47||||1.47||1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.47||||1.47|0.74|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.47||||1.47|1.01|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0|1.12|0.29
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]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.29|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.47||||1.47|1.01|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.57|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47||1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.47||||1.47||1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47||1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.47||||1.47|1.01|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47|0|1.12|0.29
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]|1.47||||1.47|0|1.12|0.29
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.47||||1.47||1.12|0.29
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]|11||||11||8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|0|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11||||11|0|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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]|11||||11|0|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11||||11|5.5|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11||||11|4.28|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|7.92|8.36|2.2
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]|11||||11|5.5|8.36|2.2
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]|11||||11|5.5|8.36|2.2
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 TRADITIONAL OF TEXAS [115503]|11||||11|8.36|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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]|11||||11|0|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11||||11|7.59|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11||||11|4.4|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11||||11||8.36|2.2
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]|11||||11|7.59|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11||||11|5.5|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11||||11|7.59|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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]|11||||11|7.59|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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|11||||11|2.2|8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|TML [1980]|TML [198000]|11||||11|7.59|8.36|2.2
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]|11||||11|4.28|8.36|2.2
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]|11||||11||8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|11||||11||8.36|2.2
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]|11||||11||8.36|2.2
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11||||11|7.59|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|11||||11|0|8.36|2.2
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]|TML WC [212537]|11||||11||8.36|2.2
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AARP [1000]|AARP [100000]|7.13||||7.13||5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AETNA [1015]|AETNA [101529]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AMBETTER [2930]|AMBETTER [293000]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.13||||7.13|3.57|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.13||||7.13|5.13|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.13||||7.13|3.57|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.13||||7.13|3.57|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.13||||7.13|5.42|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|CIGNA [1260]|CIGNA PPO [126025]|7.13||||7.13|2.85|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.13||||7.13||5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.13||||7.13|3.57|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|Self-pay|Self-pay|7.13||||7.13|1.43|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|TML [1980]|TML [198000]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.13||||7.13|2.77|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.13||||7.13||5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|UNICARE [2040]|UNICARE [204000]|7.13||||7.13||5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.13||||7.13||5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|WEB TPA [2115]|WEB TPA [211500]|7.13||||7.13|4.92|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.13||||7.13|0|5.42|1.43
36962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID|10 mL|WORKER'S COMP [2125]|TML WC [212537]|7.13||||7.13||5.42|1.43
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|198||||198|99|150.48|3.82
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]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|77.06|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|198||||198|3.82|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|198||||198|77.06|150.48|3.82
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]|198||||198|0|150.48|3.82
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]|198||||198|142.56|150.48|3.82
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]|198||||198|99|150.48|3.82
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]|198||||198|99|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|198||||198|150.48|150.48|3.82
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]|198||||198|77.06|150.48|3.82
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]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|198||||198|136.62|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|198||||198|79.2|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|198||||198|99|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|198||||198|3.82|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|198||||198|136.62|150.48|3.82
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]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|77.06|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|0|150.48|3.82
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]|198||||198|77.06|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|77.06|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|198||||198|39.6|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|198||||198|136.62|150.48|3.82
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]|198||||198|77.06|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198|99|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|198||||198|99|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198|99|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|198||||198|136.62|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198|0|150.48|3.82
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]|198||||198|0|150.48|3.82
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|198||||198|99|150.48|3.82
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.03||||3.03||2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.03||||3.03|1.52|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.03||||3.03|1.18|2.3|0.61
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]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.03||||3.03|2.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.03||||3.03|1.52|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.03||||3.03|1.52|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.03||||3.03|2.3|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.03||||3.03|2.09|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.03||||3.03|1.21|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.03||||3.03||2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.03||||3.03|2.09|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.03||||3.03|1.52|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.03||||3.03|2.09|2.3|0.61
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]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.03||||3.03|0|2.3|0.61
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]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.03||||3.03|2.09|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.03||||3.03|0.61|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.03||||3.03|2.09|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.03||||3.03|1.18|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.03||||3.03||2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.03||||3.03||2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.03||||3.03||2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.03||||3.03|2.09|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.03||||3.03|0|2.3|0.61
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]|3.03||||3.03|0|2.3|0.61
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.03||||3.03||2.3|0.61
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|792||||792||601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|792||||792|0.17|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|792||||792|308.25|601.92|0.17
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]|792||||792|0|601.92|0.17
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]|792||||792|570.24|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|792||||792|396|601.92|0.17
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]|792||||792|396|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|792||||792|601.92|601.92|0.17
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]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|792||||792|546.48|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|792||||792|316.8|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|792||||792||601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|792||||792|546.48|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|792||||792|0.17|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|792||||792|546.48|601.92|0.17
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]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|792||||792|0|601.92|0.17
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]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|792||||792|546.48|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|792||||792|158.4|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|792||||792|546.48|601.92|0.17
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]|792||||792|308.25|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|792||||792||601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|792||||792||601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|792||||792||601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|792||||792|546.48|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|792||||792|0|601.92|0.17
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]|792||||792|0|601.92|0.17
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|792||||792||601.92|0.17
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.91||||2.91||2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.91||||2.91|1.46|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.91||||2.91|1.13|2.21|0.58
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]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.91||||2.91|2.1|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.91||||2.91|1.46|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.91||||2.91|1.46|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.91||||2.91|2.21|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.91||||2.91|2.01|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.91||||2.91|1.16|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.91||||2.91||2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.91||||2.91|2.01|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.91||||2.91|1.46|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.91||||2.91|2.01|2.21|0.58
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]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.91||||2.91|0|2.21|0.58
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]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.91||||2.91|2.01|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.91||||2.91|0.58|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.91||||2.91|2.01|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.91||||2.91|1.13|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.91||||2.91||2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.91||||2.91||2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.91||||2.91||2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.91||||2.91|2.01|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.91||||2.91|0|2.21|0.58
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]|2.91||||2.91|0|2.21|0.58
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.91||||2.91||2.21|0.58
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AARP [1000]|AARP [100000]|2400||||2400||1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AMBETTER [2930]|AMBETTER [293000]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2400||||2400|1200|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2400||||2400|1728|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2400||||2400|1200|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2400||||2400|1200|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2400||||2400|1824|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|2400||||2400|960|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2400||||2400||1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2400||||2400|1200|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|Self-pay|Self-pay|2400||||2400|480|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|TML [1980]|TML [198000]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2400||||2400|934.08|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2400||||2400||1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UNICARE [2040]|UNICARE [204000]|2400||||2400||1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2400||||2400||1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|WEB TPA [2115]|WEB TPA [211500]|2400||||2400|1656|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2400||||2400|0|1824|480
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]|2400||||2400|0|1824|480
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|2400||||2400||1824|480
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AARP [1000]|AARP [100000]|1439.23||||1439.23||1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AETNA [1015]|AETNA [101529]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AMBETTER [2930]|AMBETTER [293000]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1439.23||||1439.23|719.62|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1439.23||||1439.23|1036.25|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1439.23||||1439.23|719.62|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1439.23||||1439.23|719.62|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1439.23||||1439.23|1093.81|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|1439.23||||1439.23|575.69|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1439.23||||1439.23||1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1439.23||||1439.23|719.62|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|Self-pay|Self-pay|1439.23||||1439.23|287.85|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|TML [1980]|TML [198000]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1439.23||||1439.23|560.15|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1439.23||||1439.23||1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UNICARE [2040]|UNICARE [204000]|1439.23||||1439.23||1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1439.23||||1439.23||1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|WEB TPA [2115]|WEB TPA [211500]|1439.23||||1439.23|993.07|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1439.23||||1439.23|0|1093.81|287.85
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]|1439.23||||1439.23|0|1093.81|287.85
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|1439.23||||1439.23||1093.81|287.85
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AARP [1000]|AARP [100000]|1248||||1248||948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AETNA [1015]|AETNA [101529]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AMBETTER [2930]|AMBETTER [293000]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1248||||1248|624|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1248||||1248|898.56|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1248||||1248|624|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1248||||1248|624|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1248||||1248|948.48|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|CIGNA [1260]|CIGNA PPO [126025]|1248||||1248|499.2|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1248||||1248||948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1248||||1248|624|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|Self-pay|Self-pay|1248||||1248|249.6|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|TML [1980]|TML [198000]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1248||||1248|485.72|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1248||||1248||948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|UNICARE [2040]|UNICARE [204000]|1248||||1248||948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1248||||1248||948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|WEB TPA [2115]|WEB TPA [211500]|1248||||1248|861.12|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1248||||1248|0|948.48|249.6
37000009|EAP|0370 - ANESTHESIA-GENERAL|HC ANES MAC FLAT RATE|1|WORKER'S COMP [2125]|TML WC [212537]|1248||||1248||948.48|249.6
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AARP [1000]|AARP [100000]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AETNA [1015]|AETNA [101529]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|621||||621|447.12|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|621||||621|471.96|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|621||||621|248.4|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|Self-pay|Self-pay|621||||621|124.2|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|TML [1980]|TML [198000]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|621||||621|241.69|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UNICARE [2040]|UNICARE [204000]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|621||||621|310.5|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|621||||621|428.49|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|621||||621|0|471.96|124.2
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|621||||621|310.5|471.96|124.2
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AARP [1000]|AARP [100000]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AETNA [1015]|AETNA [101529]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|288.42||||288.42|207.66|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|288.42||||288.42|219.2|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|288.42||||288.42|115.37|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|Self-pay|Self-pay|288.42||||288.42|57.68|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|TML [1980]|TML [198000]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|288.42||||288.42|112.25|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UNICARE [2040]|UNICARE [204000]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|288.42||||288.42|144.21|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|288.42||||288.42|199.01|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|288.42||||288.42|0|219.2|57.68
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|288.42||||288.42|144.21|219.2|57.68
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|97.84||||97.84||74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.84||||97.84|48.92|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.84||||97.84|38.08|74.36|19.57
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]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97.84||||97.84|70.44|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.84||||97.84|48.92|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97.84||||97.84|48.92|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97.84||||97.84|74.36|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97.84||||97.84|67.51|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|97.84||||97.84|39.14|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.84||||97.84||74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|97.84||||97.84|67.51|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.84||||97.84|48.92|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.84||||97.84|67.51|74.36|19.57
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]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.84||||97.84|0|74.36|19.57
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]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|97.84||||97.84|67.51|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|97.84||||97.84|19.57|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|97.84||||97.84|67.51|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97.84||||97.84|38.08|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.84||||97.84||74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|97.84||||97.84||74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.84||||97.84||74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|97.84||||97.84|67.51|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.84||||97.84|0|74.36|19.57
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]|97.84||||97.84|0|74.36|19.57
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|97.84||||97.84||74.36|19.57
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.56||||0.56||0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.56||||0.56|0.28|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.56||||0.56|0.22|0.43|0.11
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]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.4|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.28|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.56||||0.56|0.43|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.56||||0.56|0.39|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.56||||0.56||0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.56||||0.56|0.28|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.56||||0.56|0.39|0.43|0.11
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]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0|0.43|0.11
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]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.56||||0.56|0.11|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.56||||0.56|0.39|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.22|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.56||||0.56||0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.56||||0.56|0.39|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56|0|0.43|0.11
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]|0.56||||0.56|0|0.43|0.11
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.56||||0.56||0.43|0.11
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AARP [1000]|AARP [100000]|27.72||||27.72||21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AETNA [1015]|AETNA [101529]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AMBETTER [2930]|AMBETTER [293000]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.72||||27.72|13.86|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.72||||27.72|19.96|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.72||||27.72|13.86|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.72||||27.72|13.86|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.72||||27.72|21.07|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA PPO [126025]|27.72||||27.72|11.09|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.72||||27.72||21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.72||||27.72|13.86|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|Self-pay|Self-pay|27.72||||27.72|5.54|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|TML [1980]|TML [198000]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.72||||27.72|10.79|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.72||||27.72||21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|UNICARE [2040]|UNICARE [204000]|27.72||||27.72||21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.72||||27.72||21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|WEB TPA [2115]|WEB TPA [211500]|27.72||||27.72|19.13|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.72||||27.72|0|21.07|5.54
3726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TML WC [212537]|27.72||||27.72||21.07|5.54
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AARP [1000]|AARP [100000]|85.94||||85.94||65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA [101529]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AMBETTER [2930]|AMBETTER [293000]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|85.94||||85.94|42.97|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85.94||||85.94|61.88|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85.94||||85.94|42.97|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85.94||||85.94|42.97|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|85.94||||85.94|65.31|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA PPO [126025]|85.94||||85.94|34.38|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|85.94||||85.94||65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|85.94||||85.94|42.97|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|Self-pay|Self-pay|85.94||||85.94|17.19|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|TML [1980]|TML [198000]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85.94||||85.94|33.45|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85.94||||85.94||65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|UNICARE [2040]|UNICARE [204000]|85.94||||85.94||65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85.94||||85.94||65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|WEB TPA [2115]|WEB TPA [211500]|85.94||||85.94|59.3|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85.94||||85.94|0|65.31|17.19
3727|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TML WC [212537]|85.94||||85.94||65.31|17.19
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|152.33||||152.33||115.77|30.47
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]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152.33||||152.33|59.29|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152.33||||152.33|76.17|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152.33||||152.33|59.29|115.77|30.47
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]|152.33||||152.33|0|115.77|30.47
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]|152.33||||152.33|109.68|115.77|30.47
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]|152.33||||152.33|76.17|115.77|30.47
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]|152.33||||152.33|76.17|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152.33||||152.33|115.77|115.77|30.47
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]|152.33||||152.33|59.29|115.77|30.47
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]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152.33||||152.33|105.11|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|152.33||||152.33|60.93|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152.33||||152.33||115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|152.33||||152.33|105.11|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152.33||||152.33|76.17|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152.33||||152.33|105.11|115.77|30.47
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]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152.33||||152.33|59.29|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152.33||||152.33|0|115.77|30.47
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]|152.33||||152.33|59.29|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|152.33||||152.33|105.11|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152.33||||152.33|59.29|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|152.33||||152.33|30.47|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|152.33||||152.33|105.11|115.77|30.47
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]|152.33||||152.33|59.29|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152.33||||152.33||115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|152.33||||152.33||115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152.33||||152.33||115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|152.33||||152.33|105.11|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152.33||||152.33|0|115.77|30.47
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]|152.33||||152.33|0|115.77|30.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|152.33||||152.33||115.77|30.47
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.93||||1.93||1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.93||||1.93|0.97|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.93||||1.93|0.75|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.93||||1.93|1.39|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.93||||1.93|0.97|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.93||||1.93|0.97|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.93||||1.93|1.47|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.93||||1.93|1.33|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.93||||1.93|0.77|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.93||||1.93||1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.93||||1.93|1.33|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.93||||1.93|0.97|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.93||||1.93|1.33|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.93||||1.93|0|1.47|0.39
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]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.93||||1.93|1.33|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.93||||1.93|0.39|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.93||||1.93|1.33|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.93||||1.93|0.75|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.93||||1.93||1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.93||||1.93||1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.93||||1.93||1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.93||||1.93|1.33|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.93||||1.93|0|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.93||||1.93||1.47|0.39
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.64||||0.64||0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.64||||0.64|0.32|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.64||||0.64|0.25|0.49|0.13
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]|0.64||||0.64|0|0.49|0.13
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]|0.64||||0.64|0.46|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.64||||0.64|0.32|0.49|0.13
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]|0.64||||0.64|0.32|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.64||||0.64|0.49|0.49|0.13
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]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.64||||0.64|0.44|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.64||||0.64|0.26|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.64||||0.64||0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.64||||0.64|0.44|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.64||||0.64|0.32|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.64||||0.64|0.44|0.49|0.13
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]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.64||||0.64|0|0.49|0.13
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]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.64||||0.64|0.44|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.64||||0.64|0.13|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.64||||0.64|0.44|0.49|0.13
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]|0.64||||0.64|0.25|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.64||||0.64||0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.64||||0.64||0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.64||||0.64||0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.64||||0.64|0.44|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.64||||0.64|0|0.49|0.13
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]|0.64||||0.64|0|0.49|0.13
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.64||||0.64||0.49|0.13
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]|3.82||||3.82||2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.82||||3.82|1.91|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|2.75|2.9|0.76
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]|3.82||||3.82|1.91|2.9|0.76
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]|3.82||||3.82|1.91|2.9|0.76
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 TRADITIONAL OF TEXAS [115503]|3.82||||3.82|2.9|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.82||||3.82|2.64|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.82||||3.82|1.53|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.82||||3.82||2.9|0.76
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]|3.82||||3.82|2.64|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.82||||3.82|1.91|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.82||||3.82|2.64|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82|2.64|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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|3.82||||3.82|0.76|2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|TML [1980]|TML [198000]|3.82||||3.82|2.64|2.9|0.76
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]|3.82||||3.82|1.49|2.9|0.76
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]|3.82||||3.82||2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|3.82||||3.82||2.9|0.76
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]|3.82||||3.82||2.9|0.76
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.82||||3.82|2.64|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|3.82||||3.82|0|2.9|0.76
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]|TML WC [212537]|3.82||||3.82||2.9|0.76
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|4.84||||4.84||3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.84||||4.84|2.42|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|3.48|3.68|0.97
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]|4.84||||4.84|2.42|3.68|0.97
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]|4.84||||4.84|2.42|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.84||||4.84|3.68|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.84||||4.84|3.34|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.84||||4.84|1.94|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.84||||4.84||3.68|0.97
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]|4.84||||4.84|3.34|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.84||||4.84|2.42|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.84||||4.84|3.34|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84|3.34|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|4.84||||4.84|0.97|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|TML [1980]|TML [198000]|4.84||||4.84|3.34|3.68|0.97
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]|4.84||||4.84|1.88|3.68|0.97
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]|4.84||||4.84||3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|4.84||||4.84||3.68|0.97
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]|4.84||||4.84||3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.84||||4.84|3.34|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
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]|4.84||||4.84|0|3.68|0.97
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.84||||4.84||3.68|0.97
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AARP [1000]|AARP [100000]|280.64||||280.64||213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|280.64||||280.64|10.79|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.64||||280.64|202.06|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.64||||280.64|140.32|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.64||||280.64|140.32|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|280.64||||280.64|213.29|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|280.64||||280.64|112.26|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|280.64||||280.64||213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|280.64||||280.64|10.79|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|Self-pay|Self-pay|280.64||||280.64|56.13|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|TML [1980]|TML [198000]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.64||||280.64|109.23|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.64||||280.64||213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|280.64||||280.64||213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.64||||280.64||213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|280.64||||280.64|193.64|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.64||||280.64|0|213.29|10.79
3769|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|280.64||||280.64||213.29|10.79
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.57||||3.57||2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.57||||3.57|1.79|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.57||||3.57|1.39|2.71|0.71
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]|3.57||||3.57|0|2.71|0.71
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]|3.57||||3.57|2.57|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.57||||3.57|1.79|2.71|0.71
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]|3.57||||3.57|1.79|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.57||||3.57|2.71|2.71|0.71
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]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.57||||3.57|2.46|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.57||||3.57|1.43|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.57||||3.57||2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.57||||3.57|2.46|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.57||||3.57|1.79|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.57||||3.57|2.46|2.71|0.71
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]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.57||||3.57|0|2.71|0.71
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]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.57||||3.57|2.46|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.57||||3.57|0.71|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.57||||3.57|2.46|2.71|0.71
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]|3.57||||3.57|1.39|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.57||||3.57||2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.57||||3.57||2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.57||||3.57||2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.57||||3.57|2.46|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.57||||3.57|0|2.71|0.71
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]|3.57||||3.57|0|2.71|0.71
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.57||||3.57||2.71|0.71
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.18||||4.18||3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.18||||4.18|2.09|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.18||||4.18|1.63|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|3.01|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.18||||4.18|2.09|3.18|0.84
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]|4.18||||4.18|2.09|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.18||||4.18|3.18|3.18|0.84
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]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.18||||4.18|2.88|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.18||||4.18|1.67|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.18||||4.18||3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.18||||4.18|2.88|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.18||||4.18|2.09|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.18||||4.18|2.88|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.18||||4.18|2.88|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|Self-pay|Self-pay|4.18||||4.18|0.84|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.18||||4.18|2.88|3.18|0.84
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]|4.18||||4.18|1.63|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.18||||4.18||3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.18||||4.18||3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.18||||4.18||3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.18||||4.18|2.88|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.18||||4.18|0|3.18|0.84
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]|4.18||||4.18|0|3.18|0.84
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.18||||4.18||3.18|0.84
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]|56.04||||56.04||42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|56.04||||56.04|28.02|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|40.35|42.59|11.21
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]|56.04||||56.04|28.02|42.59|11.21
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]|56.04||||56.04|28.02|42.59|11.21
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 TRADITIONAL OF TEXAS [115503]|56.04||||56.04|42.59|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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 - GREAT WEST [126009]|56.04||||56.04|38.67|42.59|11.21
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 PPO [126025]|56.04||||56.04|22.42|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|56.04||||56.04||42.59|11.21
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]|56.04||||56.04|38.67|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|56.04||||56.04|28.02|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|56.04||||56.04|38.67|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04|38.67|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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|56.04||||56.04|11.21|42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|TML [1980]|TML [198000]|56.04||||56.04|38.67|42.59|11.21
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]|56.04||||56.04|21.81|42.59|11.21
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]|56.04||||56.04||42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|56.04||||56.04||42.59|11.21
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]|56.04||||56.04||42.59|11.21
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|56.04||||56.04|38.67|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|56.04||||56.04|0|42.59|11.21
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]|TML WC [212537]|56.04||||56.04||42.59|11.21
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|75.36||||75.36||57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.36||||75.36|2.83|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.36||||75.36|54.26|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.36||||75.36|37.68|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.36||||75.36|37.68|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.36||||75.36|57.27|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|75.36||||75.36|30.14|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.36||||75.36||57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.36||||75.36|2.83|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|75.36||||75.36|15.07|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.36||||75.36|29.33|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.36||||75.36||57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|75.36||||75.36||57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.36||||75.36||57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|75.36||||75.36|52|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.36||||75.36|0|57.27|2.83
38062|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|75.36||||75.36||57.27|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|150.74||||150.74||114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150.74||||150.74|58.67|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|150.74||||150.74|2.83|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|150.74||||150.74|58.67|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
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]|150.74||||150.74|108.53|114.56|2.83
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]|150.74||||150.74|75.37|114.56|2.83
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]|150.74||||150.74|75.37|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|150.74||||150.74|114.56|114.56|2.83
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]|150.74||||150.74|58.67|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|150.74||||150.74|104.01|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|150.74||||150.74|60.3|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|150.74||||150.74||114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|150.74||||150.74|104.01|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|150.74||||150.74|2.83|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|150.74||||150.74|104.01|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150.74||||150.74|0|114.56|2.83
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]|150.74||||150.74|58.67|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150.74||||150.74|0|114.56|2.83
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]|150.74||||150.74|58.67|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|150.74||||150.74|104.01|114.56|2.83
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]|150.74||||150.74|58.67|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|150.74||||150.74|30.15|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|150.74||||150.74|104.01|114.56|2.83
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]|150.74||||150.74|58.67|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150.74||||150.74||114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|150.74||||150.74||114.56|2.83
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]|150.74||||150.74||114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|150.74||||150.74|104.01|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
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]|150.74||||150.74|0|114.56|2.83
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|150.74||||150.74||114.56|2.83
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|354.95||||354.95||269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|354.95||||354.95|177.48|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|354.95||||354.95|138.15|269.76|70.99
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]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|354.95||||354.95|255.56|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|354.95||||354.95|177.48|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|354.95||||354.95|177.48|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|354.95||||354.95|269.76|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|354.95||||354.95|244.92|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|354.95||||354.95|141.98|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|354.95||||354.95||269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|354.95||||354.95|244.92|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|354.95||||354.95|177.48|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|354.95||||354.95|244.92|269.76|70.99
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]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|354.95||||354.95|0|269.76|70.99
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]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|354.95||||354.95|244.92|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|Self-pay|Self-pay|354.95||||354.95|70.99|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|354.95||||354.95|244.92|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|354.95||||354.95|138.15|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|354.95||||354.95||269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|354.95||||354.95||269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|354.95||||354.95||269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|354.95||||354.95|244.92|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|354.95||||354.95|0|269.76|70.99
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]|354.95||||354.95|0|269.76|70.99
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|354.95||||354.95||269.76|70.99
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AARP [1000]|AARP [100000]|625.68||||625.68||475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMBETTER [2930]|AMBETTER [293000]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|625.68||||625.68|312.84|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|625.68||||625.68|450.49|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|625.68||||625.68|312.84|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|625.68||||625.68|312.84|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|625.68||||625.68|475.52|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA [1260]|CIGNA PPO [126025]|625.68||||625.68|250.27|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|625.68||||625.68||475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|625.68||||625.68|312.84|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|Self-pay|Self-pay|625.68||||625.68|125.14|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|TML [1980]|TML [198000]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|625.68||||625.68|243.51|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|625.68||||625.68||475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNICARE [2040]|UNICARE [204000]|625.68||||625.68||475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|625.68||||625.68||475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WEB TPA [2115]|WEB TPA [211500]|625.68||||625.68|431.72|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|625.68||||625.68|0|475.52|125.14
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WORKER'S COMP [2125]|TML WC [212537]|625.68||||625.68||475.52|125.14
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]|20.79||||20.79||15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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|AMBETTER [2930]|AMBETTER [293000]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.79||||20.79|10.4|15.8|4.16
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 MEDICAID [1165]|BCBS MEDICAID [116504]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|14.97|15.8|4.16
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]|20.79||||20.79|10.4|15.8|4.16
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]|20.79||||20.79|10.4|15.8|4.16
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 TRADITIONAL OF TEXAS [115503]|20.79||||20.79|15.8|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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 - GREAT WEST [126009]|20.79||||20.79|14.35|15.8|4.16
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 PPO [126025]|20.79||||20.79|8.32|15.8|4.16
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.79||||20.79||15.8|4.16
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]|20.79||||20.79|14.35|15.8|4.16
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.79||||20.79|10.4|15.8|4.16
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.79||||20.79|14.35|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79|14.35|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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|20.79||||20.79|4.16|15.8|4.16
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|TML [1980]|TML [198000]|20.79||||20.79|14.35|15.8|4.16
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]|20.79||||20.79|8.09|15.8|4.16
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]|20.79||||20.79||15.8|4.16
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|UNICARE [2040]|UNICARE [204000]|20.79||||20.79||15.8|4.16
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]|20.79||||20.79||15.8|4.16
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|WEB TPA [2115]|WEB TPA [211500]|20.79||||20.79|14.35|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|20.79||||20.79|0|15.8|4.16
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]|TML WC [212537]|20.79||||20.79||15.8|4.16
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|248.18||||248.18||188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|248.18||||248.18|1.22|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248.18||||248.18|178.69|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248.18||||248.18|124.09|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248.18||||248.18|124.09|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|248.18||||248.18|188.62|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|248.18||||248.18|99.27|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|248.18||||248.18||188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|248.18||||248.18|1.22|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|248.18||||248.18|49.64|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|TML [1980]|TML [198000]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248.18||||248.18|96.59|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248.18||||248.18||188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|248.18||||248.18||188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248.18||||248.18||188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|248.18||||248.18|171.24|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248.18||||248.18|0|188.62|1.22
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|248.18||||248.18||188.62|1.22
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89||0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.89||||0.89|0.45|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.89||||0.89|0.35|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.64|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.45|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.89||||0.89|0.68|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.89||||0.89|0.61|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.89||||0.89|0.36|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.89||||0.89||0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.89||||0.89|0.45|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.89||||0.89|0.61|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0|0.68|0.18
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]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.18|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.89||||0.89|0.61|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.35|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.89||||0.89||0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.89||||0.89|0.61|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89|0|0.68|0.18
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]|0.89||||0.89|0|0.68|0.18
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.89||||0.89||0.68|0.18
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]|36.7||||36.7||27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMBETTER [2930]|AMBETTER [293000]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.7||||36.7|18.35|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|26.42|27.89|7.34
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]|36.7||||36.7|18.35|27.89|7.34
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]|36.7||||36.7|18.35|27.89|7.34
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 TRADITIONAL OF TEXAS [115503]|36.7||||36.7|27.89|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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 - GREAT WEST [126009]|36.7||||36.7|25.32|27.89|7.34
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 PPO [126025]|36.7||||36.7|14.68|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.7||||36.7||27.89|7.34
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]|36.7||||36.7|25.32|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.7||||36.7|18.35|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.7||||36.7|25.32|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7|25.32|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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|36.7||||36.7|7.34|27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|TML [1980]|TML [198000]|36.7||||36.7|25.32|27.89|7.34
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]|36.7||||36.7|14.28|27.89|7.34
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]|36.7||||36.7||27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNICARE [2040]|UNICARE [204000]|36.7||||36.7||27.89|7.34
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]|36.7||||36.7||27.89|7.34
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WEB TPA [2115]|WEB TPA [211500]|36.7||||36.7|25.32|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|36.7||||36.7|0|27.89|7.34
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]|TML WC [212537]|36.7||||36.7||27.89|7.34
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]|601.53||||601.53||457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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|AMBETTER [2930]|AMBETTER [293000]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|601.53||||601.53|300.77|457.16|120.31
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 MEDICAID [1165]|BCBS MEDICAID [116504]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|433.1|457.16|120.31
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]|601.53||||601.53|300.77|457.16|120.31
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]|601.53||||601.53|300.77|457.16|120.31
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 TRADITIONAL OF TEXAS [115503]|601.53||||601.53|457.16|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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 - GREAT WEST [126009]|601.53||||601.53|415.06|457.16|120.31
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 PPO [126025]|601.53||||601.53|240.61|457.16|120.31
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|601.53||||601.53||457.16|120.31
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]|601.53||||601.53|415.06|457.16|120.31
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|601.53||||601.53|300.77|457.16|120.31
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|601.53||||601.53|415.06|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53|415.06|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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|601.53||||601.53|120.31|457.16|120.31
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|TML [1980]|TML [198000]|601.53||||601.53|415.06|457.16|120.31
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]|601.53||||601.53|234.12|457.16|120.31
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]|601.53||||601.53||457.16|120.31
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|UNICARE [2040]|UNICARE [204000]|601.53||||601.53||457.16|120.31
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]|601.53||||601.53||457.16|120.31
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|WEB TPA [2115]|WEB TPA [211500]|601.53||||601.53|415.06|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|601.53||||601.53|0|457.16|120.31
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]|TML WC [212537]|601.53||||601.53||457.16|120.31
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|144.54||||144.54||109.85|0.72
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]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144.54||||144.54|56.25|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|144.54||||144.54|0.72|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|144.54||||144.54|56.25|109.85|0.72
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]|144.54||||144.54|0|109.85|0.72
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]|144.54||||144.54|104.07|109.85|0.72
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]|144.54||||144.54|72.27|109.85|0.72
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]|144.54||||144.54|72.27|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|144.54||||144.54|109.85|109.85|0.72
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]|144.54||||144.54|56.25|109.85|0.72
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]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|144.54||||144.54|99.73|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|144.54||||144.54|57.82|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|144.54||||144.54||109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|144.54||||144.54|99.73|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|144.54||||144.54|0.72|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|144.54||||144.54|99.73|109.85|0.72
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]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144.54||||144.54|56.25|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144.54||||144.54|0|109.85|0.72
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]|144.54||||144.54|56.25|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|144.54||||144.54|99.73|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144.54||||144.54|56.25|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|144.54||||144.54|28.91|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|144.54||||144.54|99.73|109.85|0.72
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]|144.54||||144.54|56.25|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144.54||||144.54||109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|144.54||||144.54||109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144.54||||144.54||109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|144.54||||144.54|99.73|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144.54||||144.54|0|109.85|0.72
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]|144.54||||144.54|0|109.85|0.72
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|144.54||||144.54||109.85|0.72
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AARP [1000]|AARP [100000]|940.32||||940.32|940.32|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA [1015]|AETNA [101529]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMBETTER [2930]|AMBETTER [293000]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|940.32||||940.32|245.06|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|940.32||||940.32|365.97|940.32|188.06
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]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|940.32||||940.32|677.03|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|940.32||||940.32|470.16|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|940.32||||940.32|470.16|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|940.32||||940.32|714.64|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|940.32||||940.32|648.82|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA [1260]|CIGNA PPO [126025]|940.32||||940.32|376.13|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|940.32||||940.32|940.32|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|940.32||||940.32|648.82|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|940.32||||940.32|245.06|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|940.32||||940.32|648.82|940.32|188.06
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]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|940.32||||940.32|0|940.32|188.06
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]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|940.32||||940.32|648.82|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|Self-pay|Self-pay|940.32||||940.32|188.06|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|TML [1980]|TML [198000]|940.32||||940.32|648.82|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|940.32||||940.32|365.97|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|940.32||||940.32|940.32|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNICARE [2040]|UNICARE [204000]|940.32||||940.32|940.32|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|940.32||||940.32|940.32|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WEB TPA [2115]|WEB TPA [211500]|940.32||||940.32|648.82|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|940.32||||940.32|0|940.32|188.06
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]|940.32||||940.32|0|940.32|188.06
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WORKER'S COMP [2125]|TML WC [212537]|940.32||||940.32|940.32|940.32|188.06
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AARP [1000]|AARP [100000]|4243.68||||4243.68|1261|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AETNA [1015]|AETNA [101529]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AMBETTER [2930]|AMBETTER [293000]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4243.68||||4243.68|632.84|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4243.68||||4243.68|3055.45|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4243.68||||4243.68|2121.84|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4243.68||||4243.68|2121.84|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4243.68||||4243.68|3225.2|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA [1260]|CIGNA PPO [126025]|4243.68||||4243.68|1697.47|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4243.68||||4243.68|1261|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4243.68||||4243.68|632.84|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|Self-pay|Self-pay|4243.68||||4243.68|848.74|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|TML [1980]|TML [198000]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4243.68||||4243.68|1651.64|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4243.68||||4243.68|1261|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UNICARE [2040]|UNICARE [204000]|4243.68||||4243.68|1261|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4243.68||||4243.68|1261|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WEB TPA [2115]|WEB TPA [211500]|4243.68||||4243.68|2928.14|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4243.68||||4243.68|0|3225.2|632.84
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WORKER'S COMP [2125]|TML WC [212537]|4243.68||||4243.68|1261|3225.2|632.84
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AARP [1000]|AARP [100000]|1412.64||||1412.64|1261|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA [1015]|AETNA [101529]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMBETTER [2930]|AMBETTER [293000]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1412.64||||1412.64|338.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1412.64||||1412.64|549.8|1261|282.53
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]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1412.64||||1412.64|1017.1|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1412.64||||1412.64|706.32|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1412.64||||1412.64|706.32|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1412.64||||1412.64|1073.61|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1412.64||||1412.64|974.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA [1260]|CIGNA PPO [126025]|1412.64||||1412.64|565.06|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1412.64||||1412.64|1261|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1412.64||||1412.64|974.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1412.64||||1412.64|338.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1412.64||||1412.64|974.72|1261|282.53
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]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1412.64||||1412.64|0|1261|282.53
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]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1412.64||||1412.64|974.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|Self-pay|Self-pay|1412.64||||1412.64|282.53|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|TML [1980]|TML [198000]|1412.64||||1412.64|974.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1412.64||||1412.64|549.8|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1412.64||||1412.64|1261|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNICARE [2040]|UNICARE [204000]|1412.64||||1412.64|1261|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1412.64||||1412.64|1261|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WEB TPA [2115]|WEB TPA [211500]|1412.64||||1412.64|974.72|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1412.64||||1412.64|0|1261|282.53
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]|1412.64||||1412.64|0|1261|282.53
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WORKER'S COMP [2125]|TML WC [212537]|1412.64||||1412.64|1261|1261|282.53
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AARP [1000]|AARP [100000]|394.56||||394.56|394.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA [1015]|AETNA [101529]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMBETTER [2930]|AMBETTER [293000]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|394.56||||394.56|92.5|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|394.56||||394.56|153.56|394.56|78.91
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]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|394.56||||394.56|284.08|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|394.56||||394.56|197.28|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|394.56||||394.56|197.28|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|394.56||||394.56|299.87|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|394.56||||394.56|272.25|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA [1260]|CIGNA PPO [126025]|394.56||||394.56|157.82|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|394.56||||394.56|394.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|394.56||||394.56|272.25|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|394.56||||394.56|92.5|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|394.56||||394.56|272.25|394.56|78.91
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]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|394.56||||394.56|0|394.56|78.91
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]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|394.56||||394.56|272.25|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|Self-pay|Self-pay|394.56||||394.56|78.91|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|TML [1980]|TML [198000]|394.56||||394.56|272.25|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|394.56||||394.56|153.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|394.56||||394.56|394.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNICARE [2040]|UNICARE [204000]|394.56||||394.56|394.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|394.56||||394.56|394.56|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WEB TPA [2115]|WEB TPA [211500]|394.56||||394.56|272.25|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|394.56||||394.56|0|394.56|78.91
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]|394.56||||394.56|0|394.56|78.91
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WORKER'S COMP [2125]|TML WC [212537]|394.56||||394.56|394.56|394.56|78.91
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|2710.31||||2710.31||2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2710.31||||2710.31|1355.16|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2710.31||||2710.31|1951.42|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2710.31||||2710.31|1355.16|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2710.31||||2710.31|1355.16|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2710.31||||2710.31|2059.84|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|2710.31||||2710.31|1084.12|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2710.31||||2710.31||2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2710.31||||2710.31|1355.16|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|2710.31||||2710.31|542.06|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2710.31||||2710.31|1054.85|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2710.31||||2710.31||2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|2710.31||||2710.31||2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2710.31||||2710.31||2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|2710.31||||2710.31|1870.11|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2710.31||||2710.31|0|2059.84|542.06
3901|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 50 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|2710.31||||2710.31||2059.84|542.06
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AARP [1000]|AARP [100000]|256.02||||256.02||194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AETNA [1015]|AETNA [101529]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMBETTER [2930]|AMBETTER [293000]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|256.02||||256.02|99.64|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|256.02||||256.02|128.01|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|256.02||||256.02|99.64|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
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]|256.02||||256.02|184.33|194.58|51.2
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]|256.02||||256.02|128.01|194.58|51.2
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]|256.02||||256.02|128.01|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|256.02||||256.02|194.58|194.58|51.2
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]|256.02||||256.02|99.64|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|256.02||||256.02|176.65|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA [1260]|CIGNA PPO [126025]|256.02||||256.02|102.41|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|256.02||||256.02||194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|256.02||||256.02|176.65|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|256.02||||256.02|128.01|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|256.02||||256.02|176.65|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|256.02||||256.02|0|194.58|51.2
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]|256.02||||256.02|99.64|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|256.02||||256.02|0|194.58|51.2
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]|256.02||||256.02|99.64|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|256.02||||256.02|176.65|194.58|51.2
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]|256.02||||256.02|99.64|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|Self-pay|Self-pay|256.02||||256.02|51.2|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|TML [1980]|TML [198000]|256.02||||256.02|176.65|194.58|51.2
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]|256.02||||256.02|99.64|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|256.02||||256.02||194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNICARE [2040]|UNICARE [204000]|256.02||||256.02||194.58|51.2
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]|256.02||||256.02||194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WEB TPA [2115]|WEB TPA [211500]|256.02||||256.02|176.65|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
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]|256.02||||256.02|0|194.58|51.2
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WORKER'S COMP [2125]|TML WC [212537]|256.02||||256.02||194.58|51.2
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AARP [1000]|AARP [100000]|2952.05||||2952.05|1261|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA [1015]|AETNA [101529]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMBETTER [2930]|AMBETTER [293000]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2952.05||||2952.05|516.18|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2952.05||||2952.05|2125.48|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2952.05||||2952.05|1476.03|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2952.05||||2952.05|1476.03|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2952.05||||2952.05|2243.56|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA [1260]|CIGNA PPO [126025]|2952.05||||2952.05|1930|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2952.05||||2952.05|1261|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2952.05||||2952.05|516.18|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|Self-pay|Self-pay|2952.05||||2952.05|590.41|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|TML [1980]|TML [198000]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2952.05||||2952.05|1261|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNICARE [2040]|UNICARE [204000]|2952.05||||2952.05|1261|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2952.05||||2952.05|1261|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WEB TPA [2115]|WEB TPA [211500]|2952.05||||2952.05|2036.91|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2952.05||||2952.05|0|2243.56|516.18
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]|2952.05||||2952.05|0|2243.56|516.18
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WORKER'S COMP [2125]|TML WC [212537]|2952.05||||2952.05|1261|2243.56|516.18
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|810.6||||810.6||616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|810.6||||810.6|405.3|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|583.63|616.06|162.12
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]|810.6||||810.6|405.3|616.06|162.12
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]|810.6||||810.6|405.3|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|810.6||||810.6|616.06|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|810.6||||810.6|559.31|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|810.6||||810.6|324.24|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|810.6||||810.6||616.06|162.12
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]|810.6||||810.6|559.31|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|810.6||||810.6|405.3|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|810.6||||810.6|559.31|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6|559.31|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|Self-pay|Self-pay|810.6||||810.6|162.12|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|810.6||||810.6|559.31|616.06|162.12
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]|810.6||||810.6|315.49|616.06|162.12
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]|810.6||||810.6||616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|810.6||||810.6||616.06|162.12
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]|810.6||||810.6||616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|810.6||||810.6|559.31|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
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]|810.6||||810.6|0|616.06|162.12
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|810.6||||810.6||616.06|162.12
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|23.33||||23.33||17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.33||||23.33|11.67|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.33||||23.33|16.8|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.33||||23.33|11.67|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.33||||23.33|11.67|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.33||||23.33|17.73|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|23.33||||23.33|9.33|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.33||||23.33||17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.33||||23.33|11.67|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|23.33||||23.33|4.67|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|TML [1980]|TML [198000]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.33||||23.33|9.08|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.33||||23.33||17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|23.33||||23.33||17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.33||||23.33||17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|23.33||||23.33|16.1|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.33||||23.33|0|17.73|4.67
39275|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|23.33||||23.33||17.73|4.67
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|116.43||||116.43||88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|116.43||||116.43|58.22|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.43||||116.43|83.83|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.43||||116.43|58.22|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.43||||116.43|58.22|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|116.43||||116.43|88.49|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|116.43||||116.43|46.57|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|116.43||||116.43||88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|116.43||||116.43|58.22|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|116.43||||116.43|23.29|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|TML [1980]|TML [198000]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.43||||116.43|45.31|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.43||||116.43||88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|116.43||||116.43||88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.43||||116.43||88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|116.43||||116.43|80.34|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.43||||116.43|0|88.49|23.29
39276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 30 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|116.43||||116.43||88.49|23.29
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|89.5||||89.5||68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.5||||89.5|44.75|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.5||||89.5|64.44|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.5||||89.5|44.75|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.5||||89.5|44.75|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|89.5||||89.5|68.02|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|89.5||||89.5|35.8|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.5||||89.5||68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.5||||89.5|44.75|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|89.5||||89.5|17.9|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.5||||89.5|34.83|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.5||||89.5||68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|89.5||||89.5||68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.5||||89.5||68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|89.5||||89.5|61.76|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.5||||89.5|0|68.02|17.9
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]|89.5||||89.5|0|68.02|17.9
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|89.5||||89.5||68.02|17.9
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|32.24||||32.24||24.5|5.98
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]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.24||||32.24|12.55|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|32.24||||32.24|5.98|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|32.24||||32.24|12.55|24.5|5.98
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]|32.24||||32.24|0|24.5|5.98
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]|32.24||||32.24|23.21|24.5|5.98
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]|32.24||||32.24|16.12|24.5|5.98
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]|32.24||||32.24|16.12|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|32.24||||32.24|24.5|24.5|5.98
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]|32.24||||32.24|12.55|24.5|5.98
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]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|32.24||||32.24|22.25|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|32.24||||32.24|12.9|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|32.24||||32.24||24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32.24||||32.24|22.25|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|32.24||||32.24|5.98|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|32.24||||32.24|22.25|24.5|5.98
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]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.24||||32.24|12.55|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.24||||32.24|0|24.5|5.98
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]|32.24||||32.24|12.55|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32.24||||32.24|22.25|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.24||||32.24|12.55|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|32.24||||32.24|6.45|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|32.24||||32.24|22.25|24.5|5.98
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]|32.24||||32.24|12.55|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.24||||32.24||24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|32.24||||32.24||24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.24||||32.24||24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|32.24||||32.24|22.25|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.24||||32.24|0|24.5|5.98
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]|32.24||||32.24|0|24.5|5.98
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|32.24||||32.24||24.5|5.98
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62.7||||62.7|0.88|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|62.7||||62.7|0.88|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.7||||62.7|45.14|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.7||||62.7|45.14|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62.7||||62.7|47.65|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|62.7||||62.7|47.65|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|62.7||||62.7|25.08|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|62.7||||62.7|25.08|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62.7||||62.7|0.88|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|62.7||||62.7|0.88|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|Self-pay|Self-pay|62.7||||62.7|12.54|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|Self-pay|Self-pay|62.7||||62.7|12.54|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|TML [1980]|TML [198000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|TML [1980]|TML [198000]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.7||||62.7|24.4|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNICARE [2040]|UNICARE [204000]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNICARE [2040]|UNICARE [204000]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|62.7||||62.7|43.26|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.7||||62.7|0|47.65|0.88
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]|62.7||||62.7|0|47.65|0.88
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]|62.7||||62.7|0|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|62.7||||62.7|31.35|47.65|0.88
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|62.7||||62.7|31.35|47.65|0.88
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AARP [1000]|AARP [100000]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|5.11|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|5.11|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|Self-pay|Self-pay|66||||66|13.2|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|69.3||||69.3||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AMBETTER [2930]|AMBETTER [293000]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69.3||||69.3|34.65|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.3||||69.3|49.9|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.3||||69.3|34.65|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.3||||69.3|34.65|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69.3||||69.3|52.67|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA PPO [126025]|69.3||||69.3|27.72|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69.3||||69.3||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69.3||||69.3|34.65|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|Self-pay|Self-pay|69.3||||69.3|13.86|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|TML [1980]|TML [198000]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.3||||69.3|26.97|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.3||||69.3||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|UNICARE [2040]|UNICARE [204000]|69.3||||69.3||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.3||||69.3||52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|WEB TPA [2115]|WEB TPA [211500]|69.3||||69.3|47.82|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.3||||69.3|0|52.67|5.11
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TML WC [212537]|69.3||||69.3||52.67|5.11
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AARP [1000]|AARP [100000]|739||||739|157.36|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AETNA [1015]|AETNA [101529]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AMBETTER [2930]|AMBETTER [293000]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|739||||739|144.95|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|739||||739|287.62|561.64|144.95
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]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|739||||739|532.08|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|739||||739|369.5|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|739||||739|369.5|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|739||||739|561.64|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|739||||739|509.91|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA [1260]|CIGNA PPO [126025]|739||||739|295.6|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|739||||739|157.36|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|739||||739|509.91|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|739||||739|144.95|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|739||||739|509.91|561.64|144.95
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]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|739||||739|0|561.64|144.95
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]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|739||||739|509.91|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|Self-pay|Self-pay|739||||739|147.8|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|TML [1980]|TML [198000]|739||||739|509.91|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|739||||739|287.62|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|739||||739|157.36|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UNICARE [2040]|UNICARE [204000]|739||||739|157.36|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|739||||739|157.36|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|WEB TPA [2115]|WEB TPA [211500]|739||||739|509.91|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|739||||739|0|561.64|144.95
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]|739||||739|0|561.64|144.95
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|WORKER'S COMP [2125]|TML WC [212537]|739||||739|157.36|561.64|144.95
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.6||||13.6||10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.6||||13.6|6.8|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.6||||13.6|9.79|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.6||||13.6|6.8|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.6||||13.6|6.8|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.6||||13.6|10.34|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|13.6||||13.6|5.44|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.6||||13.6||10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.6||||13.6|6.8|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|Self-pay|Self-pay|13.6||||13.6|2.72|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|TML [1980]|TML [198000]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.6||||13.6|5.29|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.6||||13.6||10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|13.6||||13.6||10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.6||||13.6||10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|13.6||||13.6|9.38|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.6||||13.6|0|10.34|2.72
4027|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|13.6||||13.6||10.34|2.72
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AARP [1000]|AARP [100000]|665||||665|114.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AETNA [1015]|AETNA [101529]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AMBETTER [2930]|AMBETTER [293000]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|665||||665|141.66|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|665||||665|478.8|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|665||||665|332.5|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|665||||665|332.5|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|665||||665|505.4|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA [1260]|CIGNA PPO [126025]|665||||665|299.83|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|665||||665|114.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|665||||665|141.66|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|Self-pay|Self-pay|665||||665|133|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|TML [1980]|TML [198000]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|665||||665|162.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|665||||665|114.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UNICARE [2040]|UNICARE [204000]|665||||665|114.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|665||||665|114.58|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WEB TPA [2115]|WEB TPA [211500]|665||||665|458.85|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|665||||665|0|505.4|114.58
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WORKER'S COMP [2125]|TML WC [212537]|665||||665|114.58|505.4|114.58
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AARP [1000]|AARP [100000]|808||||808|124.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AETNA [1015]|AETNA [101529]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AMBETTER [2930]|AMBETTER [293000]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|808||||808|141.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|808||||808|581.76|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|808||||808|404|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|808||||808|404|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|808||||808|614.08|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA [1260]|CIGNA PPO [126025]|808||||808|500.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|808||||808|124.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|808||||808|141.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|Self-pay|Self-pay|808||||808|161.6|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|TML [1980]|TML [198000]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|808||||808|138.66|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|808||||808|124.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UNICARE [2040]|UNICARE [204000]|808||||808|124.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|808||||808|124.15|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WEB TPA [2115]|WEB TPA [211500]|808||||808|557.52|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|808||||808|0|614.08|124.15
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WORKER'S COMP [2125]|TML WC [212537]|808||||808|124.15|614.08|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AARP [1000]|AARP [100000]|826.75||||826.75|124.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AETNA [1015]|AETNA [101529]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|826.75||||826.75|141.66|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|826.75||||826.75|595.26|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|826.75||||826.75|413.38|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|826.75||||826.75|413.38|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|826.75||||826.75|628.33|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|826.75||||826.75|500.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|826.75||||826.75|124.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|826.75||||826.75|141.66|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|Self-pay|Self-pay|826.75||||826.75|165.35|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|TML [1980]|TML [198000]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|826.75||||826.75|171.61|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|826.75||||826.75|124.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UNICARE [2040]|UNICARE [204000]|826.75||||826.75|124.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|826.75||||826.75|124.15|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|826.75||||826.75|570.46|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|826.75||||826.75|0|628.33|124.15
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|826.75||||826.75|124.15|628.33|124.15
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AARP [1000]|AARP [100000]|1020.25||||1020.25|124.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AETNA [1015]|AETNA [101529]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AMBETTER [2930]|AMBETTER [293000]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1020.25||||1020.25|141.66|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1020.25||||1020.25|734.58|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1020.25||||1020.25|510.13|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1020.25||||1020.25|510.13|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1020.25||||1020.25|775.39|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA [1260]|CIGNA PPO [126025]|1020.25||||1020.25|500.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1020.25||||1020.25|124.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1020.25||||1020.25|141.66|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|Self-pay|Self-pay|1020.25||||1020.25|204.05|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|TML [1980]|TML [198000]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1020.25||||1020.25|102.54|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1020.25||||1020.25|124.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UNICARE [2040]|UNICARE [204000]|1020.25||||1020.25|124.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1020.25||||1020.25|124.15|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WEB TPA [2115]|WEB TPA [211500]|1020.25||||1020.25|703.97|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1020.25||||1020.25|0|775.39|102.54
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WORKER'S COMP [2125]|TML WC [212537]|1020.25||||1020.25|124.15|775.39|102.54
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AARP [1000]|AARP [100000]|916||||916||696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AETNA [1015]|AETNA [101529]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|916||||916|141.66|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|916||||916|659.52|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|916||||916|458|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|916||||916|458|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|916||||916|696.16|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|916||||916|500.15|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|916||||916||696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|916||||916|141.66|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|Self-pay|Self-pay|916||||916|183.2|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|TML [1980]|TML [198000]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|916||||916|153.09|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|916||||916||696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|UNICARE [2040]|UNICARE [204000]|916||||916||696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|916||||916||696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|916||||916|632.04|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|916||||916|0|696.16|141.66
40276881|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC JOINT COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|916||||916||696.16|141.66
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AARP [1000]|AARP [100000]|1507||||1507||1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AETNA [1015]|AETNA [101529]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AMBETTER [2930]|AMBETTER [293000]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1507||||1507|753.5|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1507||||1507|1085.04|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1507||||1507|753.5|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1507||||1507|753.5|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1507||||1507|1145.32|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|CIGNA [1260]|CIGNA PPO [126025]|1507||||1507|602.8|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1507||||1507||1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1507||||1507|753.5|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|Self-pay|Self-pay|1507||||1507|301.4|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|TML [1980]|TML [198000]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1507||||1507|586.52|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1507||||1507||1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|UNICARE [2040]|UNICARE [204000]|1507||||1507||1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1507||||1507||1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|WEB TPA [2115]|WEB TPA [211500]|1507||||1507|1039.83|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1507||||1507|0|1145.32|301.4
40276937|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ULTRASOUND GUIDNC VASCLR ACCSS|1|WORKER'S COMP [2125]|TML WC [212537]|1507||||1507||1145.32|301.4
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|95.04||||95.04||72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|95.04||||95.04|47.52|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95.04||||95.04|68.43|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95.04||||95.04|47.52|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95.04||||95.04|47.52|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|95.04||||95.04|72.23|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|95.04||||95.04|38.02|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|95.04||||95.04||72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|95.04||||95.04|47.52|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|95.04||||95.04|19.01|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95.04||||95.04|36.99|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95.04||||95.04||72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|95.04||||95.04||72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95.04||||95.04||72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|95.04||||95.04|65.58|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95.04||||95.04|0|72.23|19.01
403|ERX|0250 - PHARMACY-GENERAL|AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|95.04||||95.04||72.23|19.01
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|210.08||||210.08||159.66|42.02
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]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210.08||||210.08|81.76|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|210.08||||210.08|105.04|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|210.08||||210.08|81.76|159.66|42.02
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]|210.08||||210.08|0|159.66|42.02
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]|210.08||||210.08|151.26|159.66|42.02
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]|210.08||||210.08|105.04|159.66|42.02
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]|210.08||||210.08|105.04|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|210.08||||210.08|159.66|159.66|42.02
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]|210.08||||210.08|81.76|159.66|42.02
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]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|210.08||||210.08|144.96|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|210.08||||210.08|84.03|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|210.08||||210.08||159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|210.08||||210.08|144.96|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|210.08||||210.08|105.04|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|210.08||||210.08|144.96|159.66|42.02
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]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210.08||||210.08|81.76|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210.08||||210.08|0|159.66|42.02
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]|210.08||||210.08|81.76|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|210.08||||210.08|144.96|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210.08||||210.08|81.76|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|210.08||||210.08|42.02|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|210.08||||210.08|144.96|159.66|42.02
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]|210.08||||210.08|81.76|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210.08||||210.08||159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|210.08||||210.08||159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210.08||||210.08||159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|210.08||||210.08|144.96|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210.08||||210.08|0|159.66|42.02
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]|210.08||||210.08|0|159.66|42.02
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|210.08||||210.08||159.66|42.02
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|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 MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|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|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|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|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|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01|0|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|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|AMBETTER [2930]|AMBETTER [293000]|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|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.45||||11.45||8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.45||||11.45|5.73|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.45||||11.45|4.46|8.7|2.29
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]|11.45||||11.45|0|8.7|2.29
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]|11.45||||11.45|8.24|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.45||||11.45|5.73|8.7|2.29
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]|11.45||||11.45|5.73|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.45||||11.45|8.7|8.7|2.29
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]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.45||||11.45|7.9|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.45||||11.45|4.58|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.45||||11.45||8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.45||||11.45|7.9|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.45||||11.45|5.73|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.45||||11.45|7.9|8.7|2.29
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]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.45||||11.45|0|8.7|2.29
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]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.45||||11.45|7.9|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|Self-pay|Self-pay|11.45||||11.45|2.29|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.45||||11.45|7.9|8.7|2.29
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]|11.45||||11.45|4.46|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.45||||11.45||8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.45||||11.45||8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.45||||11.45||8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.45||||11.45|7.9|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.45||||11.45|0|8.7|2.29
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]|11.45||||11.45|0|8.7|2.29
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.45||||11.45||8.7|2.29
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AARP [1000]|AARP [100000]|3509.2||||3509.2||2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA [1015]|AETNA [101529]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMBETTER [2930]|AMBETTER [293000]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3509.2||||3509.2|1754.6|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3509.2||||3509.2|2526.62|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3509.2||||3509.2|1754.6|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3509.2||||3509.2|1754.6|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3509.2||||3509.2|2666.99|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA PPO [126025]|3509.2||||3509.2|1403.68|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3509.2||||3509.2||2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GROUP PENSION ADMIN [1450]|GPA [145000]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3509.2||||3509.2|1754.6|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|PHCS [1780]|PHCS MULTIPLAN [178000]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|Self-pay|Self-pay|3509.2||||3509.2|701.84|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|TML [1980]|TML [198000]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3509.2||||3509.2|1365.78|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3509.2||||3509.2||2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNICARE [2040]|UNICARE [204000]|3509.2||||3509.2||2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3509.2||||3509.2||2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WEB TPA [2115]|WEB TPA [211500]|3509.2||||3509.2|2421.35|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3509.2||||3509.2|0|2666.99|701.84
40698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TML WC [212537]|3509.2||||3509.2||2666.99|701.84
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AARP [1000]|AARP [100000]|5450.87||||5450.87||4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AETNA [1015]|AETNA [101529]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMBETTER [2930]|AMBETTER [293000]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5450.87||||5450.87|2725.44|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5450.87||||5450.87|3924.63|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5450.87||||5450.87|2725.44|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5450.87||||5450.87|2725.44|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5450.87||||5450.87|4142.66|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|CIGNA [1260]|CIGNA PPO [126025]|5450.87||||5450.87|2180.35|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5450.87||||5450.87||4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|GROUP PENSION ADMIN [1450]|GPA [145000]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5450.87||||5450.87|2725.44|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|Self-pay|Self-pay|5450.87||||5450.87|1090.17|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|TML [1980]|TML [198000]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5450.87||||5450.87|2121.48|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5450.87||||5450.87||4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNICARE [2040]|UNICARE [204000]|5450.87||||5450.87||4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5450.87||||5450.87||4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WEB TPA [2115]|WEB TPA [211500]|5450.87||||5450.87|3761.1|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5450.87||||5450.87|0|4142.66|1090.17
40699|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 220 MCG/ACTUATION HFA AEROSOL INHALER|12 g|WORKER'S COMP [2125]|TML WC [212537]|5450.87||||5450.87||4142.66|1090.17
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33||||33|13.44|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|23.76|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33||||33|25.08|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|33||||33|13.2|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33||||33|13.44|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|33||||33|6.6|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|12.84|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|16.5|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|33||||33|22.77|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33|0|25.08|6.6
407|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|33||||33|16.5|25.08|6.6
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AARP [1000]|AARP [100000]|224.4||||224.4||170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AETNA [1015]|AETNA [101529]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AMBETTER [2930]|AMBETTER [293000]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|224.4||||224.4|112.2|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|224.4||||224.4|161.57|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|224.4||||224.4|112.2|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|224.4||||224.4|112.2|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|224.4||||224.4|170.54|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|CIGNA [1260]|CIGNA PPO [126025]|224.4||||224.4|89.76|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|224.4||||224.4||170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|224.4||||224.4|112.2|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|Self-pay|Self-pay|224.4||||224.4|44.88|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|TML [1980]|TML [198000]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|224.4||||224.4|87.34|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|224.4||||224.4||170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|UNICARE [2040]|UNICARE [204000]|224.4||||224.4||170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|224.4||||224.4||170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|WEB TPA [2115]|WEB TPA [211500]|224.4||||224.4|154.84|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|224.4||||224.4|0|170.54|44.88
40801045|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN 0.7% SODIUM CHLORIDE IV|125 mL|WORKER'S COMP [2125]|TML WC [212537]|224.4||||224.4||170.54|44.88
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]|52.8||||52.8||40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|5.11|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|38.02|40.13|5.11
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]|52.8||||52.8|26.4|40.13|5.11
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]|52.8||||52.8|26.4|40.13|5.11
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 TRADITIONAL OF TEXAS [115503]|52.8||||52.8|40.13|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8||40.13|5.11
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]|52.8||||52.8|36.43|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|5.11|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8|36.43|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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|52.8||||52.8|10.56|40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|40.13|5.11
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]|52.8||||52.8|20.55|40.13|5.11
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]|52.8||||52.8||40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8||40.13|5.11
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]|52.8||||52.8||40.13|5.11
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|52.8||||52.8|0|40.13|5.11
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]|TML WC [212537]|52.8||||52.8||40.13|5.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.21|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.53||||0.53|0.27|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.53||||0.53|0.21|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0.38|0.4|0.11
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]|0.53||||0.53|0.27|0.4|0.11
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]|0.53||||0.53|0.27|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.53||||0.53|0.4|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.53||||0.53|0.37|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.53||||0.53|0.21|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.53||||0.53||0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.53||||0.53|0.27|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.53||||0.53|0.37|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.11|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.53||||0.53|0.37|0.4|0.11
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]|0.53||||0.53|0.21|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.53||||0.53||0.4|0.11
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]|0.53||||0.53||0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.53||||0.53|0.37|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
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]|0.53||||0.53|0|0.4|0.11
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.53||||0.53||0.4|0.11
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AARP [1000]|AARP [100000]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AETNA [1015]|AETNA [101529]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AMBETTER [2930]|AMBETTER [293000]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.27||||24.27|0.42|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.27||||24.27|17.47|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.27||||24.27|18.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|CIGNA [1260]|CIGNA PPO [126025]|24.27||||24.27|9.71|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.27||||24.27|0.42|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|Self-pay|Self-pay|24.27||||24.27|4.85|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|TML [1980]|TML [198000]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.27||||24.27|9.45|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|UNICARE [2040]|UNICARE [204000]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.27||||24.27|12.14|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|WEB TPA [2115]|WEB TPA [211500]|24.27||||24.27|16.75|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.27||||24.27|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|1 mL|WORKER'S COMP [2125]|TML WC [212537]|24.27||||24.27|12.14|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AMBETTER [2930]|AMBETTER [293000]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|101.78||||101.78|0.42|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|73.28|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
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 TRADITIONAL OF TEXAS [115503]|101.78||||101.78|77.35|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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 - GREAT WEST [126009]|101.78||||101.78|70.23|77.35|0.42
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 PPO [126025]|101.78||||101.78|40.71|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|70.23|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|101.78||||101.78|0.42|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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|101.78||||101.78|20.36|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|TML [1980]|TML [198000]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|39.61|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UNICARE [2040]|UNICARE [204000]|101.78||||101.78|50.89|77.35|0.42
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]|101.78||||101.78|50.89|77.35|0.42
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|WEB TPA [2115]|WEB TPA [211500]|101.78||||101.78|70.23|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|101.78||||101.78|0|77.35|0.42
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]|TML WC [212537]|101.78||||101.78|50.89|77.35|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AARP [1000]|AARP [100000]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AETNA [1015]|AETNA [101529]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AMBETTER [2930]|AMBETTER [293000]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.27||||24.27|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.27||||24.27|17.47|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.27||||24.27|18.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|CIGNA [1260]|CIGNA PPO [126025]|24.27||||24.27|9.71|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.27||||24.27|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|Self-pay|Self-pay|24.27||||24.27|4.85|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|TML [1980]|TML [198000]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.27||||24.27|9.45|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|UNICARE [2040]|UNICARE [204000]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.27||||24.27|12.14|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|WEB TPA [2115]|WEB TPA [211500]|24.27||||24.27|16.75|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.27||||24.27|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|1 mL|WORKER'S COMP [2125]|TML WC [212537]|24.27||||24.27|12.14|68.32|0.42
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]|44.09||||44.09|22.05|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AMBETTER [2930]|AMBETTER [293000]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|44.09||||44.09|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|31.74|68.32|0.42
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]|44.09||||44.09|22.05|68.32|0.42
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]|44.09||||44.09|22.05|68.32|0.42
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 TRADITIONAL OF TEXAS [115503]|44.09||||44.09|33.51|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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 - GREAT WEST [126009]|44.09||||44.09|30.42|68.32|0.42
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 PPO [126025]|44.09||||44.09|17.64|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|44.09||||44.09|22.05|68.32|0.42
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]|44.09||||44.09|30.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|44.09||||44.09|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|44.09||||44.09|30.42|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|30.42|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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|44.09||||44.09|8.82|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|TML [1980]|TML [198000]|44.09||||44.09|30.42|68.32|0.42
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]|44.09||||44.09|17.16|68.32|0.42
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]|44.09||||44.09|22.05|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UNICARE [2040]|UNICARE [204000]|44.09||||44.09|22.05|68.32|0.42
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]|44.09||||44.09|22.05|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|WEB TPA [2115]|WEB TPA [211500]|44.09||||44.09|30.42|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|44.09||||44.09|0|68.32|0.42
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]|TML WC [212537]|44.09||||44.09|22.05|68.32|0.42
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]|89.9||||89.9|44.95|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AMBETTER [2930]|AMBETTER [293000]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|89.9||||89.9|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|64.73|68.32|0.42
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]|89.9||||89.9|44.95|68.32|0.42
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]|89.9||||89.9|44.95|68.32|0.42
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 TRADITIONAL OF TEXAS [115503]|89.9||||89.9|68.32|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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 - GREAT WEST [126009]|89.9||||89.9|62.03|68.32|0.42
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 PPO [126025]|89.9||||89.9|35.96|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|89.9||||89.9|44.95|68.32|0.42
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]|89.9||||89.9|62.03|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|89.9||||89.9|0.42|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|89.9||||89.9|62.03|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|62.03|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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|89.9||||89.9|17.98|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|TML [1980]|TML [198000]|89.9||||89.9|62.03|68.32|0.42
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]|89.9||||89.9|34.99|68.32|0.42
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]|89.9||||89.9|44.95|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UNICARE [2040]|UNICARE [204000]|89.9||||89.9|44.95|68.32|0.42
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]|89.9||||89.9|44.95|68.32|0.42
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|WEB TPA [2115]|WEB TPA [211500]|89.9||||89.9|62.03|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|89.9||||89.9|0|68.32|0.42
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]|TML WC [212537]|89.9||||89.9|44.95|68.32|0.42
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]|1347.86||||1347.86||1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1347.86||||1347.86|155.9|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|970.46|1024.37|155.9
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]|1347.86||||1347.86|673.93|1024.37|155.9
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]|1347.86||||1347.86|673.93|1024.37|155.9
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 TRADITIONAL OF TEXAS [115503]|1347.86||||1347.86|1024.37|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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 - GREAT WEST [126009]|1347.86||||1347.86|930.02|1024.37|155.9
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 PPO [126025]|1347.86||||1347.86|539.14|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1347.86||||1347.86||1024.37|155.9
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]|1347.86||||1347.86|930.02|1024.37|155.9
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1347.86||||1347.86|155.9|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1347.86||||1347.86|930.02|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86|930.02|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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|1347.86||||1347.86|269.57|1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|TML [1980]|TML [198000]|1347.86||||1347.86|930.02|1024.37|155.9
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]|1347.86||||1347.86|524.59|1024.37|155.9
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]|1347.86||||1347.86||1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNICARE [2040]|UNICARE [204000]|1347.86||||1347.86||1024.37|155.9
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]|1347.86||||1347.86||1024.37|155.9
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|1347.86||||1347.86|930.02|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|1347.86||||1347.86|0|1024.37|155.9
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]|TML WC [212537]|1347.86||||1347.86||1024.37|155.9
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AARP [1000]|AARP [100000]|178.2||||178.2||135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA [1015]|AETNA [101529]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMBETTER [2930]|AMBETTER [293000]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|178.2||||178.2|89.1|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|178.2||||178.2|69.36|135.43|35.64
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]|178.2||||178.2|0|135.43|35.64
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]|178.2||||178.2|128.3|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178.2||||178.2|89.1|135.43|35.64
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]|178.2||||178.2|89.1|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|178.2||||178.2|135.43|135.43|35.64
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]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|178.2||||178.2|122.96|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA [1260]|CIGNA PPO [126025]|178.2||||178.2|71.28|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|178.2||||178.2||135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|178.2||||178.2|122.96|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|178.2||||178.2|89.1|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|178.2||||178.2|122.96|135.43|35.64
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]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178.2||||178.2|0|135.43|35.64
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]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|178.2||||178.2|122.96|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|Self-pay|Self-pay|178.2||||178.2|35.64|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|TML [1980]|TML [198000]|178.2||||178.2|122.96|135.43|35.64
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]|178.2||||178.2|69.36|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178.2||||178.2||135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNICARE [2040]|UNICARE [204000]|178.2||||178.2||135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178.2||||178.2||135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WEB TPA [2115]|WEB TPA [211500]|178.2||||178.2|122.96|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178.2||||178.2|0|135.43|35.64
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]|178.2||||178.2|0|135.43|35.64
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WORKER'S COMP [2125]|TML WC [212537]|178.2||||178.2||135.43|35.64
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AARP [1000]|AARP [100000]|3.06||||3.06|1.53|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AETNA [1015]|AETNA [101529]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.06||||3.06|1.19|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.06||||3.06|4.1|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.06||||3.06|1.19|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
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]|3.06||||3.06|2.2|4.1|0.61
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]|3.06||||3.06|1.53|4.1|0.61
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]|3.06||||3.06|1.53|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.06||||3.06|2.33|4.1|0.61
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]|3.06||||3.06|1.19|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.06||||3.06|2.11|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|3.06||||3.06|1.22|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.06||||3.06|1.53|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.06||||3.06|2.11|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.06||||3.06|4.1|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.06||||3.06|2.11|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.06||||3.06|0|4.1|0.61
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]|3.06||||3.06|1.19|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.06||||3.06|0|4.1|0.61
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]|3.06||||3.06|1.19|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.06||||3.06|2.11|4.1|0.61
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]|3.06||||3.06|1.19|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|Self-pay|Self-pay|3.06||||3.06|0.61|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|TML [1980]|TML [198000]|3.06||||3.06|2.11|4.1|0.61
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]|3.06||||3.06|1.19|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.06||||3.06|1.53|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNICARE [2040]|UNICARE [204000]|3.06||||3.06|1.53|4.1|0.61
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]|3.06||||3.06|1.53|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|3.06||||3.06|2.11|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
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]|3.06||||3.06|0|4.1|0.61
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|3.06||||3.06|1.53|4.1|0.61
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AARP [1000]|AARP [100000]|2.64||||2.64|1.32|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|0|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64|0|2.01|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]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|0|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|0.03|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|1.9|2.01|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]|2.64||||2.64|1.32|2.01|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]|2.64||||2.64|1.32|2.01|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 TRADITIONAL OF TEXAS [115503]|2.64||||2.64|2.01|2.01|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]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|0|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64|1.32|2.01|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]|2.64||||2.64|1.82|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|0.03|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|1.82|2.01|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]|2.64||||2.64|1.03|2.01|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|2.64||||2.64|0.53|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|TML [1980]|TML [198000]|2.64||||2.64|1.82|2.01|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]|2.64||||2.64|1.03|2.01|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]|2.64||||2.64|1.32|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|2.64||||2.64|1.32|2.01|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]|2.64||||2.64|1.32|2.01|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|2.01|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]|2.64||||2.64|0|2.01|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]|2.64||||2.64|0|2.01|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]|TML WC [212537]|2.64||||2.64|1.32|2.01|0.03
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AARP [1000]|AARP [100000]|184.53||||184.53||140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AETNA [1015]|AETNA [101529]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMBETTER [2930]|AMBETTER [293000]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.53||||184.53|71.82|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.53||||184.53|92.27|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.53||||184.53|71.82|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
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]|184.53||||184.53|132.86|140.24|36.91
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]|184.53||||184.53|92.27|140.24|36.91
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]|184.53||||184.53|92.27|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.53||||184.53|140.24|140.24|36.91
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]|184.53||||184.53|71.82|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.53||||184.53|127.33|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA [1260]|CIGNA PPO [126025]|184.53||||184.53|73.81|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.53||||184.53||140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|184.53||||184.53|127.33|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.53||||184.53|92.27|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.53||||184.53|127.33|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.53||||184.53|0|140.24|36.91
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]|184.53||||184.53|71.82|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.53||||184.53|0|140.24|36.91
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]|184.53||||184.53|71.82|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|184.53||||184.53|127.33|140.24|36.91
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]|184.53||||184.53|71.82|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|Self-pay|Self-pay|184.53||||184.53|36.91|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|TML [1980]|TML [198000]|184.53||||184.53|127.33|140.24|36.91
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]|184.53||||184.53|71.82|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.53||||184.53||140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNICARE [2040]|UNICARE [204000]|184.53||||184.53||140.24|36.91
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]|184.53||||184.53||140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WEB TPA [2115]|WEB TPA [211500]|184.53||||184.53|127.33|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
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]|184.53||||184.53|0|140.24|36.91
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WORKER'S COMP [2125]|TML WC [212537]|184.53||||184.53||140.24|36.91
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AARP [1000]|AARP [100000]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AARP [1000]|AARP [100000]|7.73||||7.73||5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA [1015]|AETNA [101529]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA [1015]|AETNA [101529]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMBETTER [2930]|AMBETTER [293000]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMBETTER [2930]|AMBETTER [293000]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.73||||7.73|3.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.73||||7.73|3.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.73||||7.73|3.01|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|5.57|5.87|1.55
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]|7.73||||7.73|5.57|5.87|1.55
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]|7.73||||7.73|3.87|5.87|1.55
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]|7.73||||7.73|3.87|5.87|1.55
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]|7.73||||7.73|3.87|5.87|1.55
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]|7.73||||7.73|3.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.73||||7.73|5.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.73||||7.73|5.87|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA PPO [126025]|7.73||||7.73|3.09|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA PPO [126025]|7.73||||7.73|3.09|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.73||||7.73||5.87|1.55
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]|7.73||||7.73|5.33|5.87|1.55
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]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.73||||7.73|3.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.73||||7.73|3.87|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.73||||7.73|5.33|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.73||||7.73|5.33|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|Self-pay|Self-pay|7.73||||7.73|1.55|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|Self-pay|Self-pay|7.73||||7.73|1.55|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|TML [1980]|TML [198000]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|TML [1980]|TML [198000]|7.73||||7.73|5.33|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73|3.01|5.87|1.55
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]|7.73||||7.73||5.87|1.55
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]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNICARE [2040]|UNICARE [204000]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNICARE [2040]|UNICARE [204000]|7.73||||7.73||5.87|1.55
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]|7.73||||7.73||5.87|1.55
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]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WEB TPA [2115]|WEB TPA [211500]|7.73||||7.73|5.33|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WEB TPA [2115]|WEB TPA [211500]|7.73||||7.73|5.33|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
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]|7.73||||7.73|0|5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TML WC [212537]|7.73||||7.73||5.87|1.55
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TML WC [212537]|7.73||||7.73||5.87|1.55
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AARP [1000]|AARP [100000]|23.96||||23.96||18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AETNA [1015]|AETNA [101529]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMBETTER [2930]|AMBETTER [293000]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.96||||23.96|11.98|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.96||||23.96|17.25|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.96||||23.96|11.98|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.96||||23.96|11.98|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.96||||23.96|18.21|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|CIGNA [1260]|CIGNA PPO [126025]|23.96||||23.96|9.58|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.96||||23.96||18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.96||||23.96|11.98|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|Self-pay|Self-pay|23.96||||23.96|4.79|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|TML [1980]|TML [198000]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.96||||23.96|9.33|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.96||||23.96||18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UNICARE [2040]|UNICARE [204000]|23.96||||23.96||18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.96||||23.96||18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WEB TPA [2115]|WEB TPA [211500]|23.96||||23.96|16.53|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.96||||23.96|0|18.21|4.79
40813818|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT WRAP|15 g|WORKER'S COMP [2125]|TML WC [212537]|23.96||||23.96||18.21|4.79
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|383.33||||383.33||291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|383.33||||383.33|191.67|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|383.33||||383.33|276|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|383.33||||383.33|191.67|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|383.33||||383.33|191.67|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|383.33||||383.33|291.33|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|383.33||||383.33|153.33|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|383.33||||383.33||291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|383.33||||383.33|191.67|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|383.33||||383.33|76.67|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|383.33||||383.33|149.19|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|383.33||||383.33||291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|383.33||||383.33||291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|383.33||||383.33||291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|383.33||||383.33|264.5|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|383.33||||383.33|0|291.33|76.67
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]|383.33||||383.33|0|291.33|76.67
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|383.33||||383.33||291.33|76.67
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]|252.65||||252.65||192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMBETTER [2930]|AMBETTER [293000]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|252.65||||252.65|126.33|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|181.91|192.01|50.53
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]|252.65||||252.65|126.33|192.01|50.53
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]|252.65||||252.65|126.33|192.01|50.53
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 TRADITIONAL OF TEXAS [115503]|252.65||||252.65|192.01|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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 - GREAT WEST [126009]|252.65||||252.65|174.33|192.01|50.53
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 PPO [126025]|252.65||||252.65|101.06|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|252.65||||252.65||192.01|50.53
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]|252.65||||252.65|174.33|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|252.65||||252.65|126.33|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|252.65||||252.65|174.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65|174.33|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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|252.65||||252.65|50.53|192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|TML [1980]|TML [198000]|252.65||||252.65|174.33|192.01|50.53
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]|252.65||||252.65|98.33|192.01|50.53
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]|252.65||||252.65||192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNICARE [2040]|UNICARE [204000]|252.65||||252.65||192.01|50.53
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]|252.65||||252.65||192.01|50.53
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WEB TPA [2115]|WEB TPA [211500]|252.65||||252.65|174.33|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|252.65||||252.65|0|192.01|50.53
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]|TML WC [212537]|252.65||||252.65||192.01|50.53
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AARP [1000]|AARP [100000]|174.9||||174.9||132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA [1015]|AETNA [101529]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMBETTER [2930]|AMBETTER [293000]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|174.9||||174.9|87.45|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174.9||||174.9|125.93|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174.9||||174.9|87.45|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174.9||||174.9|87.45|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|174.9||||174.9|132.92|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA [1260]|CIGNA PPO [126025]|174.9||||174.9|69.96|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|174.9||||174.9||132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|174.9||||174.9|87.45|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|Self-pay|Self-pay|174.9||||174.9|34.98|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|TML [1980]|TML [198000]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174.9||||174.9|68.07|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174.9||||174.9||132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNICARE [2040]|UNICARE [204000]|174.9||||174.9||132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174.9||||174.9||132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WEB TPA [2115]|WEB TPA [211500]|174.9||||174.9|120.68|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174.9||||174.9|0|132.92|34.98
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]|174.9||||174.9|0|132.92|34.98
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WORKER'S COMP [2125]|TML WC [212537]|174.9||||174.9||132.92|34.98
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AARP [1000]|AARP [100000]|15750||||15750||11970|3150
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|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AETNA [1015]|AETNA [101529]|15750||||15750|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AMBETTER [2930]|AMBETTER [293000]|15750||||15750|0|11970|3150
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|6129.9|11970|3150
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|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15750||||15750|7875|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15750||||15750|6129.9|11970|3150
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|0|11970|3150
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|11340|11970|3150
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|11970|3150
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|7875|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15750||||15750|11970|11970|3150
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|6129.9|11970|3150
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|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15750||||15750|10867.5|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|CIGNA [1260]|CIGNA PPO [126025]|15750||||15750|6300|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15750||||15750||11970|3150
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|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15750||||15750|7875|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15750||||15750|10867.5|11970|3150
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|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15750||||15750|0|11970|3150
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|6129.9|11970|3150
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|0|11970|3150
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|0|11970|3150
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|6129.9|11970|3150
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|11970|3150
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|6129.9|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|Self-pay|Self-pay|15750||||15750|3150|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|TML [1980]|TML [198000]|15750||||15750|10867.5|11970|3150
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|6129.9|11970|3150
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||11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UNICARE [2040]|UNICARE [204000]|15750||||15750||11970|3150
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||11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|WEB TPA [2115]|WEB TPA [211500]|15750||||15750|10867.5|11970|3150
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|0|11970|3150
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|0|11970|3150
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|WORKER'S COMP [2125]|TML WC [212537]|15750||||15750||11970|3150
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AARP [1000]|AARP [100000]|10.31||||10.31||7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA [1015]|AETNA [101529]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMBETTER [2930]|AMBETTER [293000]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.31||||10.31|5.16|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|7.42|7.84|2.06
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]|10.31||||10.31|5.16|7.84|2.06
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]|10.31||||10.31|5.16|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.31||||10.31|7.84|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.31||||10.31|7.11|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|10.31||||10.31|4.12|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.31||||10.31||7.84|2.06
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]|10.31||||10.31|7.11|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.31||||10.31|5.16|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.31||||10.31|7.11|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31|7.11|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|Self-pay|Self-pay|10.31||||10.31|2.06|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|TML [1980]|TML [198000]|10.31||||10.31|7.11|7.84|2.06
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]|10.31||||10.31|4.01|7.84|2.06
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]|10.31||||10.31||7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNICARE [2040]|UNICARE [204000]|10.31||||10.31||7.84|2.06
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]|10.31||||10.31||7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WEB TPA [2115]|WEB TPA [211500]|10.31||||10.31|7.11|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
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]|10.31||||10.31|0|7.84|2.06
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|10.31||||10.31||7.84|2.06
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AARP [1000]|AARP [100000]|525.58||||525.58||399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AETNA [1015]|AETNA [101529]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AMBETTER [2930]|AMBETTER [293000]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|525.58||||525.58|0.17|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|378.42|399.44|0.17
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]|525.58||||525.58|262.79|399.44|0.17
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]|525.58||||525.58|262.79|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|525.58||||525.58|399.44|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|525.58||||525.58|362.65|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|CIGNA [1260]|CIGNA PPO [126025]|525.58||||525.58|210.23|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|525.58||||525.58||399.44|0.17
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]|525.58||||525.58|362.65|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|525.58||||525.58|0.17|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|525.58||||525.58|362.65|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58|362.65|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|Self-pay|Self-pay|525.58||||525.58|105.12|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|TML [1980]|TML [198000]|525.58||||525.58|362.65|399.44|0.17
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]|525.58||||525.58|204.56|399.44|0.17
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]|525.58||||525.58||399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UNICARE [2040]|UNICARE [204000]|525.58||||525.58||399.44|0.17
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]|525.58||||525.58||399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|WEB TPA [2115]|WEB TPA [211500]|525.58||||525.58|362.65|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
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]|525.58||||525.58|0|399.44|0.17
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|WORKER'S COMP [2125]|TML WC [212537]|525.58||||525.58||399.44|0.17
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.37||||0.37||0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.37||||0.37|0.19|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.37||||0.37|0.27|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.37||||0.37|0.19|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.37||||0.37|0.19|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.37||||0.37|0.28|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.37||||0.37|0.15|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.37||||0.37||0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.37||||0.37|0.19|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|Self-pay|Self-pay|0.37||||0.37|0.07|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.37||||0.37|0.14|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.37||||0.37||0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.37||||0.37||0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.37||||0.37||0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.37||||0.37|0.26|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.37||||0.37|0|0.28|0.07
4083077|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 325 MG (65 MG IRON) TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.37||||0.37||0.28|0.07
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AARP [1000]|AARP [100000]|6.3||||6.3||4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AETNA [1015]|AETNA [101529]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.3||||6.3|3.15|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|4.54|4.79|1.26
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]|6.3||||6.3|3.15|4.79|1.26
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]|6.3||||6.3|3.15|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.3||||6.3|4.79|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.3||||6.3|4.35|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.3||||6.3|2.52|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.3||||6.3||4.79|1.26
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]|6.3||||6.3|4.35|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.3||||6.3|3.15|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.3||||6.3|4.35|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3|4.35|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|Self-pay|Self-pay|6.3||||6.3|1.26|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|TML [1980]|TML [198000]|6.3||||6.3|4.35|4.79|1.26
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]|6.3||||6.3|2.45|4.79|1.26
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]|6.3||||6.3||4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|6.3||||6.3||4.79|1.26
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]|6.3||||6.3||4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.3||||6.3|4.35|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
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]|6.3||||6.3|0|4.79|1.26
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.3||||6.3||4.79|1.26
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AARP [1000]|AARP [100000]|33.97||||33.97|16.99|25.82|3.56
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]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AETNA [1015]|AETNA [101529]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.97||||33.97|13.22|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33.97||||33.97|3.56|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33.97||||33.97|13.22|25.82|3.56
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]|33.97||||33.97|0|25.82|3.56
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]|33.97||||33.97|24.46|25.82|3.56
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]|33.97||||33.97|16.99|25.82|3.56
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]|33.97||||33.97|16.99|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33.97||||33.97|25.82|25.82|3.56
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]|33.97||||33.97|13.22|25.82|3.56
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]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33.97||||33.97|23.44|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|33.97||||33.97|13.59|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33.97||||33.97|16.99|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.97||||33.97|23.44|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33.97||||33.97|3.56|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33.97||||33.97|23.44|25.82|3.56
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]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.97||||33.97|13.22|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.97||||33.97|0|25.82|3.56
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]|33.97||||33.97|13.22|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.97||||33.97|23.44|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.97||||33.97|13.22|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|Self-pay|Self-pay|33.97||||33.97|6.79|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|TML [1980]|TML [198000]|33.97||||33.97|23.44|25.82|3.56
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]|33.97||||33.97|13.22|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.97||||33.97|16.99|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|33.97||||33.97|16.99|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.97||||33.97|16.99|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|33.97||||33.97|23.44|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.97||||33.97|0|25.82|3.56
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]|33.97||||33.97|0|25.82|3.56
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|33.97||||33.97|16.99|25.82|3.56
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AARP [1000]|AARP [100000]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AETNA [1015]|AETNA [101529]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AMBETTER [2930]|AMBETTER [293000]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|385.44||||385.44|0.16|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|385.44||||385.44|150.01|292.93|0.16
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]|385.44||||385.44|0|292.93|0.16
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]|385.44||||385.44|277.52|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|385.44||||385.44|192.72|292.93|0.16
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]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|385.44||||385.44|292.93|292.93|0.16
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]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|385.44||||385.44|265.95|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA [1260]|CIGNA PPO [126025]|385.44||||385.44|154.18|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|385.44||||385.44|265.95|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|385.44||||385.44|0.16|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|385.44||||385.44|265.95|292.93|0.16
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]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|385.44||||385.44|0|292.93|0.16
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]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|385.44||||385.44|265.95|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|Self-pay|Self-pay|385.44||||385.44|77.09|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|TML [1980]|TML [198000]|385.44||||385.44|265.95|292.93|0.16
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]|385.44||||385.44|150.01|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UNICARE [2040]|UNICARE [204000]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|385.44||||385.44|192.72|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|WEB TPA [2115]|WEB TPA [211500]|385.44||||385.44|265.95|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|385.44||||385.44|0|292.93|0.16
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]|385.44||||385.44|0|292.93|0.16
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|WORKER'S COMP [2125]|TML WC [212537]|385.44||||385.44|192.72|292.93|0.16
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AARP [1000]|AARP [100000]|630||||630||478.8|126
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|0|478.8|126
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|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AMBETTER [2930]|AMBETTER [293000]|630||||630|0|478.8|126
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|245.2|478.8|126
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|0|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|630||||630|315|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|630||||630|245.2|478.8|126
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|0|478.8|126
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|453.6|478.8|126
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|478.8|126
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|315|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|630||||630|478.8|478.8|126
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|245.2|478.8|126
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|0|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|630||||630|434.7|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA PPO [126025]|630||||630|252|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|630||||630||478.8|126
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|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|630||||630|315|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|630||||630|434.7|478.8|126
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|0|478.8|126
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|478.8|126
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|245.2|478.8|126
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|0|478.8|126
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|478.8|126
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|245.2|478.8|126
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|478.8|126
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|245.2|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|Self-pay|Self-pay|630||||630|126|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|TML [1980]|TML [198000]|630||||630|434.7|478.8|126
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|245.2|478.8|126
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||478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UNICARE [2040]|UNICARE [204000]|630||||630||478.8|126
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||478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|WEB TPA [2115]|WEB TPA [211500]|630||||630|434.7|478.8|126
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|0|478.8|126
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|0|478.8|126
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|WORKER'S COMP [2125]|TML WC [212537]|630||||630||478.8|126
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|861.25|1309.1|344.5
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|0|1309.1|344.5
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|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AMBETTER [2930]|AMBETTER [293000]|1722.5||||1722.5|0|1309.1|344.5
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|670.4|1309.1|344.5
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|0|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1722.5||||1722.5|861.25|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1722.5||||1722.5|670.4|1309.1|344.5
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|0|1309.1|344.5
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|1240.2|1309.1|344.5
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|1309.1|344.5
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|861.25|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1722.5||||1722.5|1309.1|1309.1|344.5
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|670.4|1309.1|344.5
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|0|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1722.5||||1722.5|1188.53|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA PPO [126025]|1722.5||||1722.5|689|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1722.5||||1722.5|861.25|1309.1|344.5
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|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1722.5||||1722.5|861.25|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1722.5||||1722.5|1188.53|1309.1|344.5
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|0|1309.1|344.5
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|1309.1|344.5
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|670.4|1309.1|344.5
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|0|1309.1|344.5
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|1309.1|344.5
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|670.4|1309.1|344.5
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|1309.1|344.5
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|670.4|1309.1|344.5
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|344.5|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|TML [1980]|TML [198000]|1722.5||||1722.5|1188.53|1309.1|344.5
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|670.4|1309.1|344.5
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|861.25|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UNICARE [2040]|UNICARE [204000]|1722.5||||1722.5|861.25|1309.1|344.5
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|861.25|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|WEB TPA [2115]|WEB TPA [211500]|1722.5||||1722.5|1188.53|1309.1|344.5
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|0|1309.1|344.5
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|0|1309.1|344.5
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|WORKER'S COMP [2125]|TML WC [212537]|1722.5||||1722.5|861.25|1309.1|344.5
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||19|5
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|0|19|5
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|0|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AMBETTER [2930]|AMBETTER [293000]|25||||25|0|19|5
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|9.73|19|5
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|0|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25||||25|17.34|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25||||25|9.73|19|5
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|0|19|5
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|18|19|5
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|19|5
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|12.5|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25||||25|19|19|5
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|9.73|19|5
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|0|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25||||25|17.25|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|CIGNA [1260]|CIGNA PPO [126025]|25||||25|10|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25||||25||19|5
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|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25||||25|17.34|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25||||25|17.25|19|5
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|0|19|5
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|0|19|5
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|9.73|19|5
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|0|19|5
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|0|19|5
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|9.73|19|5
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|19|5
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|9.73|19|5
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|5|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|TML [1980]|TML [198000]|25||||25|17.25|19|5
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|9.73|19|5
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||19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UNICARE [2040]|UNICARE [204000]|25||||25||19|5
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||19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|WEB TPA [2115]|WEB TPA [211500]|25||||25|17.25|19|5
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|0|19|5
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|0|19|5
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|WORKER'S COMP [2125]|TML WC [212537]|25||||25||19|5
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AARP [1000]|AARP [100000]|384||||384|192|291.84|76.8
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|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AETNA [1015]|AETNA [101529]|384||||384|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AMBETTER [2930]|AMBETTER [293000]|384||||384|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|384||||384|149.45|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|384||||384|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|384||||384|192|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|384||||384|149.45|291.84|76.8
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|0|291.84|76.8
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|276.48|291.84|76.8
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|291.84|76.8
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|192|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|384||||384|291.84|291.84|76.8
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|149.45|291.84|76.8
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|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|384||||384|264.96|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|CIGNA [1260]|CIGNA PPO [126025]|384||||384|153.6|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|384||||384|192|291.84|76.8
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|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|384||||384|192|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|384||||384|264.96|291.84|76.8
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|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|384||||384|0|291.84|76.8
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|149.45|291.84|76.8
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|0|291.84|76.8
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|291.84|76.8
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|149.45|291.84|76.8
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|291.84|76.8
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|149.45|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|Self-pay|Self-pay|384||||384|76.8|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|TML [1980]|TML [198000]|384||||384|264.96|291.84|76.8
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|149.45|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|384||||384|192|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UNICARE [2040]|UNICARE [204000]|384||||384|192|291.84|76.8
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|192|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|WEB TPA [2115]|WEB TPA [211500]|384||||384|264.96|291.84|76.8
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|0|291.84|76.8
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|0|291.84|76.8
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|WORKER'S COMP [2125]|TML WC [212537]|384||||384|192|291.84|76.8
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|52.7|80.1|21.08
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|0|80.1|21.08
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|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AMBETTER [2930]|AMBETTER [293000]|105.4||||105.4|0|80.1|21.08
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|41.02|80.1|21.08
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|0|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.4||||105.4|52.7|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|105.4||||105.4|41.02|80.1|21.08
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|0|80.1|21.08
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|75.89|80.1|21.08
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|80.1|21.08
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|52.7|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|105.4||||105.4|80.1|80.1|21.08
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|41.02|80.1|21.08
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|0|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|105.4||||105.4|72.73|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|CIGNA [1260]|CIGNA PPO [126025]|105.4||||105.4|42.16|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.4||||105.4|52.7|80.1|21.08
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|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.4||||105.4|52.7|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.4||||105.4|72.73|80.1|21.08
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|0|80.1|21.08
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|80.1|21.08
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|41.02|80.1|21.08
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|0|80.1|21.08
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|80.1|21.08
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|41.02|80.1|21.08
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|80.1|21.08
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|41.02|80.1|21.08
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|21.08|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|TML [1980]|TML [198000]|105.4||||105.4|72.73|80.1|21.08
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|41.02|80.1|21.08
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|52.7|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UNICARE [2040]|UNICARE [204000]|105.4||||105.4|52.7|80.1|21.08
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|52.7|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|WEB TPA [2115]|WEB TPA [211500]|105.4||||105.4|72.73|80.1|21.08
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|0|80.1|21.08
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|0|80.1|21.08
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|WORKER'S COMP [2125]|TML WC [212537]|105.4||||105.4|52.7|80.1|21.08
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AARP [1000]|AARP [100000]|6216||||6216||4724.16|1243.2
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|0|4724.16|1243.2
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|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AMBETTER [2930]|AMBETTER [293000]|6216||||6216|0|4724.16|1243.2
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|2419.27|4724.16|1243.2
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|0|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6216||||6216|3108|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6216||||6216|2419.27|4724.16|1243.2
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|0|4724.16|1243.2
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|4475.52|4724.16|1243.2
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|4724.16|1243.2
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|3108|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6216||||6216|4724.16|4724.16|1243.2
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|2419.27|4724.16|1243.2
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|0|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6216||||6216|4289.04|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA PPO [126025]|6216||||6216|2486.4|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6216||||6216||4724.16|1243.2
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|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6216||||6216|3108|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6216||||6216|4289.04|4724.16|1243.2
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|0|4724.16|1243.2
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|4724.16|1243.2
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|2419.27|4724.16|1243.2
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|0|4724.16|1243.2
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|4724.16|1243.2
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|2419.27|4724.16|1243.2
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|4724.16|1243.2
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|2419.27|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|Self-pay|Self-pay|6216||||6216|1243.2|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|TML [1980]|TML [198000]|6216||||6216|4289.04|4724.16|1243.2
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|2419.27|4724.16|1243.2
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||4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UNICARE [2040]|UNICARE [204000]|6216||||6216||4724.16|1243.2
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||4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|WEB TPA [2115]|WEB TPA [211500]|6216||||6216|4289.04|4724.16|1243.2
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|0|4724.16|1243.2
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|0|4724.16|1243.2
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TML WC [212537]|6216||||6216||4724.16|1243.2
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|225|342|90
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|0|342|90
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|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AMBETTER [2930]|AMBETTER [293000]|450||||450|0|342|90
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|175.14|342|90
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|0|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|450||||450|225|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|450||||450|175.14|342|90
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|0|342|90
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|324|342|90
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|342|90
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|225|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|450||||450|342|342|90
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|175.14|342|90
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|0|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|450||||450|310.5|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|CIGNA [1260]|CIGNA PPO [126025]|450||||450|180|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|450||||450|225|342|90
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|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|450||||450|225|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|450||||450|310.5|342|90
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|0|342|90
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|342|90
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|175.14|342|90
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|0|342|90
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|342|90
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|175.14|342|90
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|342|90
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|175.14|342|90
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|90|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|TML [1980]|TML [198000]|450||||450|310.5|342|90
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|175.14|342|90
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|225|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UNICARE [2040]|UNICARE [204000]|450||||450|225|342|90
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|225|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|WEB TPA [2115]|WEB TPA [211500]|450||||450|310.5|342|90
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|0|342|90
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|0|342|90
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|WORKER'S COMP [2125]|TML WC [212537]|450||||450|225|342|90
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AARP [1000]|AARP [100000]|12.81||||12.81||9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AETNA [1015]|AETNA [101529]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMBETTER [2930]|AMBETTER [293000]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.81||||12.81|6.41|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.81||||12.81|9.22|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.81||||12.81|6.41|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.81||||12.81|6.41|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.81||||12.81|9.74|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|CIGNA [1260]|CIGNA PPO [126025]|12.81||||12.81|5.12|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.81||||12.81||9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|GROUP PENSION ADMIN [1450]|GPA [145000]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.81||||12.81|6.41|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|PHCS [1780]|PHCS MULTIPLAN [178000]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|Self-pay|Self-pay|12.81||||12.81|2.56|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|TML [1980]|TML [198000]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.81||||12.81|4.99|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.81||||12.81||9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UNICARE [2040]|UNICARE [204000]|12.81||||12.81||9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.81||||12.81||9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WEB TPA [2115]|WEB TPA [211500]|12.81||||12.81|8.84|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.81||||12.81|0|9.74|2.56
40840092|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL CAMPHOR (CARMEX) OINTMENT|9.923 g|WORKER'S COMP [2125]|TML WC [212537]|12.81||||12.81||9.74|2.56
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AARP [1000]|AARP [100000]|9360||||9360|4680|7113.6|1872
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|0|7113.6|1872
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|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AMBETTER [2930]|AMBETTER [293000]|9360||||9360|0|7113.6|1872
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|3642.91|7113.6|1872
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|0|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9360||||9360|4680|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9360||||9360|3642.91|7113.6|1872
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|0|7113.6|1872
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|6739.2|7113.6|1872
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|7113.6|1872
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|4680|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9360||||9360|7113.6|7113.6|1872
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|3642.91|7113.6|1872
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|0|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9360||||9360|6458.4|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|CIGNA [1260]|CIGNA PPO [126025]|9360||||9360|3744|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9360||||9360|4680|7113.6|1872
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|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9360||||9360|4680|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9360||||9360|6458.4|7113.6|1872
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|0|7113.6|1872
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|7113.6|1872
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|3642.91|7113.6|1872
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|0|7113.6|1872
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|7113.6|1872
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|3642.91|7113.6|1872
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|7113.6|1872
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|3642.91|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|Self-pay|Self-pay|9360||||9360|1872|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|TML [1980]|TML [198000]|9360||||9360|6458.4|7113.6|1872
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|3642.91|7113.6|1872
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|4680|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UNICARE [2040]|UNICARE [204000]|9360||||9360|4680|7113.6|1872
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|4680|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|WEB TPA [2115]|WEB TPA [211500]|9360||||9360|6458.4|7113.6|1872
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|0|7113.6|1872
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|0|7113.6|1872
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|WORKER'S COMP [2125]|TML WC [212537]|9360||||9360|4680|7113.6|1872
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AARP [1000]|AARP [100000]|700.85||||700.85||532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AETNA [1015]|AETNA [101529]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AMBETTER [2930]|AMBETTER [293000]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|700.85||||700.85|350.43|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|700.85||||700.85|504.61|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|700.85||||700.85|350.43|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|700.85||||700.85|350.43|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|700.85||||700.85|532.65|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|CIGNA [1260]|CIGNA PPO [126025]|700.85||||700.85|280.34|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|700.85||||700.85||532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|700.85||||700.85|350.43|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|Self-pay|Self-pay|700.85||||700.85|140.17|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|TML [1980]|TML [198000]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|700.85||||700.85|272.77|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|700.85||||700.85||532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|UNICARE [2040]|UNICARE [204000]|700.85||||700.85||532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|700.85||||700.85||532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|WEB TPA [2115]|WEB TPA [211500]|700.85||||700.85|483.59|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|700.85||||700.85|0|532.65|140.17
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|0.25 mL|WORKER'S COMP [2125]|TML WC [212537]|700.85||||700.85||532.65|140.17
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AARP [1000]|AARP [100000]|27.46||||27.46||20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AETNA [1015]|AETNA [101529]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.46||||27.46|13.73|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.46||||27.46|19.77|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.46||||27.46|13.73|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.46||||27.46|13.73|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.46||||27.46|20.87|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|27.46||||27.46|10.98|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.46||||27.46||20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.46||||27.46|13.73|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|Self-pay|Self-pay|27.46||||27.46|5.49|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|TML [1980]|TML [198000]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.46||||27.46|10.69|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.46||||27.46||20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|27.46||||27.46||20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.46||||27.46||20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|27.46||||27.46|18.95|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.46||||27.46|0|20.87|5.49
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|27.46||||27.46||20.87|5.49
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.4||||0.4||0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.4||||0.4|0.2|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.4||||0.4|0.29|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.4||||0.4|0.2|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.4||||0.4|0.2|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.4||||0.4|0.3|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.4||||0.4||0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.4||||0.4|0.2|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|Self-pay|Self-pay|0.4||||0.4|0.08|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|TML [1980]|TML [198000]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.4||||0.4|0.16|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.4||||0.4||0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|0.4||||0.4||0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.4||||0.4||0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.4||||0.4|0.28|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.4||||0.4|0|0.3|0.08
40840265|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.4||||0.4||0.3|0.08
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|36.36||||36.36|18.18|27.63|3.56
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]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.36||||36.36|14.15|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|36.36||||36.36|3.56|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|36.36||||36.36|14.15|27.63|3.56
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]|36.36||||36.36|0|27.63|3.56
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]|36.36||||36.36|26.18|27.63|3.56
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]|36.36||||36.36|18.18|27.63|3.56
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]|36.36||||36.36|18.18|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|36.36||||36.36|27.63|27.63|3.56
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]|36.36||||36.36|14.15|27.63|3.56
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]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|36.36||||36.36|25.09|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|36.36||||36.36|14.54|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|36.36||||36.36|18.18|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.36||||36.36|25.09|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|36.36||||36.36|3.56|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|36.36||||36.36|25.09|27.63|3.56
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]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.36||||36.36|14.15|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.36||||36.36|0|27.63|3.56
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]|36.36||||36.36|14.15|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.36||||36.36|25.09|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.36||||36.36|14.15|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|36.36||||36.36|7.27|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|36.36||||36.36|25.09|27.63|3.56
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]|36.36||||36.36|14.15|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.36||||36.36|18.18|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|36.36||||36.36|18.18|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.36||||36.36|18.18|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|36.36||||36.36|25.09|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.36||||36.36|0|27.63|3.56
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]|36.36||||36.36|0|27.63|3.56
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|36.36||||36.36|18.18|27.63|3.56
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AARP [1000]|AARP [100000]|3706.56||||3706.56|1853.28|2816.99|252.75
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]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AETNA [1015]|AETNA [101529]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMBETTER [2930]|AMBETTER [293000]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3706.56||||3706.56|1442.59|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3706.56||||3706.56|252.75|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3706.56||||3706.56|1442.59|2816.99|252.75
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]|3706.56||||3706.56|0|2816.99|252.75
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]|3706.56||||3706.56|2668.72|2816.99|252.75
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]|3706.56||||3706.56|1853.28|2816.99|252.75
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]|3706.56||||3706.56|1853.28|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3706.56||||3706.56|2816.99|2816.99|252.75
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]|3706.56||||3706.56|1442.59|2816.99|252.75
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]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3706.56||||3706.56|2557.53|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA [1260]|CIGNA PPO [126025]|3706.56||||3706.56|1482.62|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3706.56||||3706.56|1853.28|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3706.56||||3706.56|2557.53|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3706.56||||3706.56|252.75|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3706.56||||3706.56|2557.53|2816.99|252.75
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]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3706.56||||3706.56|1442.59|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3706.56||||3706.56|0|2816.99|252.75
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]|3706.56||||3706.56|1442.59|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3706.56||||3706.56|2557.53|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3706.56||||3706.56|1442.59|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|Self-pay|Self-pay|3706.56||||3706.56|741.31|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|TML [1980]|TML [198000]|3706.56||||3706.56|2557.53|2816.99|252.75
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]|3706.56||||3706.56|1442.59|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3706.56||||3706.56|1853.28|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNICARE [2040]|UNICARE [204000]|3706.56||||3706.56|1853.28|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3706.56||||3706.56|1853.28|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WEB TPA [2115]|WEB TPA [211500]|3706.56||||3706.56|2557.53|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3706.56||||3706.56|0|2816.99|252.75
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]|3706.56||||3706.56|0|2816.99|252.75
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WORKER'S COMP [2125]|TML WC [212537]|3706.56||||3706.56|1853.28|2816.99|252.75
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]|37.49||||37.49|18.75|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.49||||37.49|0.16|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|26.99|28.49|0.16
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]|37.49||||37.49|18.75|28.49|0.16
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]|37.49||||37.49|18.75|28.49|0.16
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 TRADITIONAL OF TEXAS [115503]|37.49||||37.49|28.49|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.49||||37.49|25.87|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|37.49||||37.49|15|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.49||||37.49|18.75|28.49|0.16
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]|37.49||||37.49|25.87|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.49||||37.49|0.16|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.49||||37.49|25.87|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|25.87|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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|37.49||||37.49|7.5|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|TML [1980]|TML [198000]|37.49||||37.49|25.87|28.49|0.16
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]|37.49||||37.49|14.59|28.49|0.16
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]|37.49||||37.49|18.75|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|37.49||||37.49|18.75|28.49|0.16
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]|37.49||||37.49|18.75|28.49|0.16
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|37.49||||37.49|25.87|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|37.49||||37.49|0|28.49|0.16
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]|TML WC [212537]|37.49||||37.49|18.75|28.49|0.16
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AARP [1000]|AARP [100000]|1107.48||||1107.48||841.68|221.5
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]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AETNA [1015]|AETNA [101529]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMBETTER [2930]|AMBETTER [293000]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1107.48||||1107.48|431.03|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1107.48||||1107.48|553.74|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1107.48||||1107.48|431.03|841.68|221.5
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]|1107.48||||1107.48|0|841.68|221.5
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]|1107.48||||1107.48|797.39|841.68|221.5
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]|1107.48||||1107.48|553.74|841.68|221.5
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]|1107.48||||1107.48|553.74|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1107.48||||1107.48|841.68|841.68|221.5
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]|1107.48||||1107.48|431.03|841.68|221.5
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]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1107.48||||1107.48|764.16|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1107.48||||1107.48|442.99|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1107.48||||1107.48||841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1107.48||||1107.48|764.16|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1107.48||||1107.48|553.74|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1107.48||||1107.48|764.16|841.68|221.5
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]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1107.48||||1107.48|431.03|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1107.48||||1107.48|0|841.68|221.5
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]|1107.48||||1107.48|431.03|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1107.48||||1107.48|764.16|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1107.48||||1107.48|431.03|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|Self-pay|Self-pay|1107.48||||1107.48|221.5|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|TML [1980]|TML [198000]|1107.48||||1107.48|764.16|841.68|221.5
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]|1107.48||||1107.48|431.03|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1107.48||||1107.48||841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNICARE [2040]|UNICARE [204000]|1107.48||||1107.48||841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1107.48||||1107.48||841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WEB TPA [2115]|WEB TPA [211500]|1107.48||||1107.48|764.16|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1107.48||||1107.48|0|841.68|221.5
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]|1107.48||||1107.48|0|841.68|221.5
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1107.48||||1107.48||841.68|221.5
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AARP [1000]|AARP [100000]|545.31||||545.31||414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AETNA [1015]|AETNA [101529]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|545.31||||545.31|44.28|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545.31||||545.31|392.62|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545.31||||545.31|272.66|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545.31||||545.31|272.66|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|545.31||||545.31|414.44|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|545.31||||545.31|218.12|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|545.31||||545.31||414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|545.31||||545.31|44.28|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|Self-pay|Self-pay|545.31||||545.31|109.06|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|TML [1980]|TML [198000]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545.31||||545.31|212.23|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545.31||||545.31||414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|UNICARE [2040]|UNICARE [204000]|545.31||||545.31||414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545.31||||545.31||414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|545.31||||545.31|376.26|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545.31||||545.31|0|414.44|44.28
40840295|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS,TETANUS VACCINE WRAP RECORD|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|545.31||||545.31||414.44|44.28
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AARP [1000]|AARP [100000]|16.64||||16.64|8.32|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AETNA [1015]|AETNA [101529]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AMBETTER [2930]|AMBETTER [293000]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.64||||16.64|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|11.98|63.81|0.94
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]|16.64||||16.64|8.32|63.81|0.94
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]|16.64||||16.64|8.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.64||||16.64|12.65|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.64||||16.64|11.48|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|CIGNA [1260]|CIGNA PPO [126025]|16.64||||16.64|6.66|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.64||||16.64|8.32|63.81|0.94
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]|16.64||||16.64|11.48|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.64||||16.64|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.64||||16.64|11.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|11.48|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|Self-pay|Self-pay|16.64||||16.64|3.33|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|TML [1980]|TML [198000]|16.64||||16.64|11.48|63.81|0.94
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]|16.64||||16.64|6.48|63.81|0.94
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]|16.64||||16.64|8.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UNICARE [2040]|UNICARE [204000]|16.64||||16.64|8.32|63.81|0.94
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]|16.64||||16.64|8.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|WEB TPA [2115]|WEB TPA [211500]|16.64||||16.64|11.48|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
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]|16.64||||16.64|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|WORKER'S COMP [2125]|TML WC [212537]|16.64||||16.64|8.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AARP [1000]|AARP [100000]|83.96||||83.96|41.98|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AETNA [1015]|AETNA [101529]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AMBETTER [2930]|AMBETTER [293000]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.96||||83.96|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|60.45|63.81|0.94
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]|83.96||||83.96|41.98|63.81|0.94
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]|83.96||||83.96|41.98|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.96||||83.96|63.81|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.96||||83.96|57.93|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|CIGNA [1260]|CIGNA PPO [126025]|83.96||||83.96|33.58|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.96||||83.96|41.98|63.81|0.94
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]|83.96||||83.96|57.93|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.96||||83.96|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.96||||83.96|57.93|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|57.93|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|Self-pay|Self-pay|83.96||||83.96|16.79|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|TML [1980]|TML [198000]|83.96||||83.96|57.93|63.81|0.94
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]|83.96||||83.96|32.68|63.81|0.94
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]|83.96||||83.96|41.98|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UNICARE [2040]|UNICARE [204000]|83.96||||83.96|41.98|63.81|0.94
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]|83.96||||83.96|41.98|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|WEB TPA [2115]|WEB TPA [211500]|83.96||||83.96|57.93|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
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]|83.96||||83.96|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|WORKER'S COMP [2125]|TML WC [212537]|83.96||||83.96|41.98|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|28.51|63.81|0.94
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]|39.6||||39.6|19.8|63.81|0.94
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]|39.6||||39.6|19.8|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|63.81|0.94
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]|39.6||||39.6|27.32|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|0.94|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|27.32|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|Self-pay|Self-pay|39.6||||39.6|7.92|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|63.81|0.94
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]|39.6||||39.6|15.41|63.81|0.94
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]|39.6||||39.6|19.8|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|63.81|0.94
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]|39.6||||39.6|19.8|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
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]|39.6||||39.6|0|63.81|0.94
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|63.81|0.94
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||13|1.6
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|0|13|1.6
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|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AMBETTER [2930]|AMBETTER [293000]|8||||8|0|13|1.6
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|3.11|13|1.6
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|0|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8||||8|13|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8||||8|3.11|13|1.6
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|0|13|1.6
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|5.76|13|1.6
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|13|1.6
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|4|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8||||8|6.08|13|1.6
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|3.11|13|1.6
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|0|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8||||8|5.52|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|CIGNA [1260]|CIGNA PPO [126025]|8||||8|3.2|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8||||8||13|1.6
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|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8||||8|13|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8||||8|5.52|13|1.6
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|0|13|1.6
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|13|1.6
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|3.11|13|1.6
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|0|13|1.6
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|13|1.6
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|3.11|13|1.6
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|13|1.6
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|3.11|13|1.6
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|1.6|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|TML [1980]|TML [198000]|8||||8|5.52|13|1.6
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|3.11|13|1.6
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||13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UNICARE [2040]|UNICARE [204000]|8||||8||13|1.6
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||13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|WEB TPA [2115]|WEB TPA [211500]|8||||8|5.52|13|1.6
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|0|13|1.6
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|0|13|1.6
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|WORKER'S COMP [2125]|TML WC [212537]|8||||8||13|1.6
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||50160|13200
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|0|50160|13200
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|0|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AMBETTER [2930]|AMBETTER [293000]|66000||||66000|0|50160|13200
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|25687.2|50160|13200
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|0|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66000||||66000|22616.93|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66000||||66000|25687.2|50160|13200
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|0|50160|13200
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|47520|50160|13200
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|50160|13200
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|33000|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66000||||66000|50160|50160|13200
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|25687.2|50160|13200
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|0|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66000||||66000|45540|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|CIGNA [1260]|CIGNA PPO [126025]|66000||||66000|26400|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66000||||66000||50160|13200
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|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66000||||66000|22616.93|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66000||||66000|45540|50160|13200
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|0|50160|13200
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|0|50160|13200
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|25687.2|50160|13200
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|0|50160|13200
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|0|50160|13200
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|25687.2|50160|13200
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|50160|13200
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|25687.2|50160|13200
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|13200|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|TML [1980]|TML [198000]|66000||||66000|45540|50160|13200
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|25687.2|50160|13200
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||50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UNICARE [2040]|UNICARE [204000]|66000||||66000||50160|13200
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||50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|WEB TPA [2115]|WEB TPA [211500]|66000||||66000|45540|50160|13200
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|0|50160|13200
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|0|50160|13200
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|WORKER'S COMP [2125]|TML WC [212537]|66000||||66000||50160|13200
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AARP [1000]|AARP [100000]|201.96||||201.96||153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AETNA [1015]|AETNA [101529]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AMBETTER [2930]|AMBETTER [293000]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|201.96||||201.96|100.98|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|201.96||||201.96|145.41|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|201.96||||201.96|100.98|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|201.96||||201.96|100.98|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|201.96||||201.96|153.49|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|CIGNA [1260]|CIGNA PPO [126025]|201.96||||201.96|80.78|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|201.96||||201.96||153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|201.96||||201.96|100.98|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|Self-pay|Self-pay|201.96||||201.96|40.39|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|TML [1980]|TML [198000]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|201.96||||201.96|78.6|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|201.96||||201.96||153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|UNICARE [2040]|UNICARE [204000]|201.96||||201.96||153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|201.96||||201.96||153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|WEB TPA [2115]|WEB TPA [211500]|201.96||||201.96|139.35|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|201.96||||201.96|0|153.49|40.39
40840638|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 1 MG/ML IN SODIUM CHLORIDE 0.9% 30 ML PCA SYRINGE (4 HOUR LOCKOUT)|30 mL|WORKER'S COMP [2125]|TML WC [212537]|201.96||||201.96||153.49|40.39
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AARP [1000]|AARP [100000]|2.24||||2.24||1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA [1015]|AETNA [101529]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.24||||2.24|1.12|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.24||||2.24|1.61|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.24||||2.24|1.12|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.24||||2.24|1.12|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.24||||2.24|1.7|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.24||||2.24|0.9|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.24||||2.24||1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.24||||2.24|1.12|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|Self-pay|Self-pay|2.24||||2.24|0.45|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|TML [1980]|TML [198000]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.24||||2.24|0.87|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.24||||2.24||1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNICARE [2040]|UNICARE [204000]|2.24||||2.24||1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.24||||2.24||1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.24||||2.24|1.55|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.24||||2.24|0|1.7|0.45
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]|2.24||||2.24|0|1.7|0.45
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.24||||2.24||1.7|0.45
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]|1.56||||1.56||1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.56||||1.56|0.78|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|1.12|1.19|0.31
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]|1.56||||1.56|0.78|1.19|0.31
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]|1.56||||1.56|0.78|1.19|0.31
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 TRADITIONAL OF TEXAS [115503]|1.56||||1.56|1.19|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.56||||1.56|1.08|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.56||||1.56|0.62|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.56||||1.56||1.19|0.31
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]|1.56||||1.56|1.08|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.56||||1.56|0.78|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.56||||1.56|1.08|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56|1.08|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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|1.56||||1.56|0.31|1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|TML [1980]|TML [198000]|1.56||||1.56|1.08|1.19|0.31
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]|1.56||||1.56|0.61|1.19|0.31
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]|1.56||||1.56||1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNICARE [2040]|UNICARE [204000]|1.56||||1.56||1.19|0.31
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]|1.56||||1.56||1.19|0.31
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.56||||1.56|1.08|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|1.56||||1.56|0|1.19|0.31
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]|TML WC [212537]|1.56||||1.56||1.19|0.31
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AARP [1000]|AARP [100000]|670.56||||670.56||509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AMBETTER [2930]|AMBETTER [293000]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|670.56||||670.56|335.28|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|670.56||||670.56|260.98|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|482.8|509.63|134.11
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]|670.56||||670.56|335.28|509.63|134.11
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]|670.56||||670.56|335.28|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|670.56||||670.56|509.63|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|670.56||||670.56|462.69|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|CIGNA [1260]|CIGNA PPO [126025]|670.56||||670.56|268.22|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|670.56||||670.56||509.63|134.11
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]|670.56||||670.56|462.69|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|670.56||||670.56|335.28|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|670.56||||670.56|462.69|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|670.56||||670.56|462.69|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|Self-pay|Self-pay|670.56||||670.56|134.11|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|TML [1980]|TML [198000]|670.56||||670.56|462.69|509.63|134.11
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]|670.56||||670.56|260.98|509.63|134.11
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]|670.56||||670.56||509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UNICARE [2040]|UNICARE [204000]|670.56||||670.56||509.63|134.11
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]|670.56||||670.56||509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|WEB TPA [2115]|WEB TPA [211500]|670.56||||670.56|462.69|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
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]|670.56||||670.56|0|509.63|134.11
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|WORKER'S COMP [2125]|TML WC [212537]|670.56||||670.56||509.63|134.11
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AARP [1000]|AARP [100000]|34.98||||34.98||26.58|7
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]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AETNA [1015]|AETNA [101529]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMBETTER [2930]|AMBETTER [293000]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.98||||34.98|13.61|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|34.98||||34.98|17.49|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|34.98||||34.98|13.61|26.58|7
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]|34.98||||34.98|0|26.58|7
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]|34.98||||34.98|25.19|26.58|7
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]|34.98||||34.98|17.49|26.58|7
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]|34.98||||34.98|17.49|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|34.98||||34.98|26.58|26.58|7
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]|34.98||||34.98|13.61|26.58|7
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]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|34.98||||34.98|24.14|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|34.98||||34.98|13.99|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|34.98||||34.98||26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.98||||34.98|24.14|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|34.98||||34.98|17.49|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|34.98||||34.98|24.14|26.58|7
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]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.98||||34.98|0|26.58|7
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]|34.98||||34.98|13.61|26.58|7
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]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.98||||34.98|0|26.58|7
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]|34.98||||34.98|13.61|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.98||||34.98|24.14|26.58|7
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]|34.98||||34.98|13.61|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|Self-pay|Self-pay|34.98||||34.98|7|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|TML [1980]|TML [198000]|34.98||||34.98|24.14|26.58|7
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]|34.98||||34.98|13.61|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.98||||34.98||26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNICARE [2040]|UNICARE [204000]|34.98||||34.98||26.58|7
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]|34.98||||34.98||26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WEB TPA [2115]|WEB TPA [211500]|34.98||||34.98|24.14|26.58|7
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]|34.98||||34.98|0|26.58|7
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]|34.98||||34.98|0|26.58|7
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|34.98||||34.98||26.58|7
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AARP [1000]|AARP [100000]|6600||||6600||5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AMBETTER [2930]|AMBETTER [293000]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6600||||6600|3300|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6600||||6600|4752|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6600||||6600|3300|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6600||||6600|3300|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6600||||6600|5016|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA [1260]|CIGNA PPO [126025]|6600||||6600|2640|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6600||||6600||5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6600||||6600|3300|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|Self-pay|Self-pay|6600||||6600|1320|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|TML [1980]|TML [198000]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6600||||6600|2568.72|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6600||||6600||5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|UNICARE [2040]|UNICARE [204000]|6600||||6600||5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6600||||6600||5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|WEB TPA [2115]|WEB TPA [211500]|6600||||6600|4554|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6600||||6600|0|5016|1320
40842115|ERX|0250 - PHARMACY-GENERAL|PANTOPRAZOLE 40 MG/100 ML NS IVPB SIMPLE|100 mL|WORKER'S COMP [2125]|TML WC [212537]|6600||||6600||5016|1320
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]|436.92||||436.92||332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AMBETTER [2930]|AMBETTER [293000]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|436.92||||436.92|218.46|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|314.58|332.06|87.38
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]|436.92||||436.92|218.46|332.06|87.38
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]|436.92||||436.92|218.46|332.06|87.38
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 TRADITIONAL OF TEXAS [115503]|436.92||||436.92|332.06|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|436.92||||436.92|301.47|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|436.92||||436.92|174.77|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|436.92||||436.92||332.06|87.38
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]|436.92||||436.92|301.47|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|436.92||||436.92|218.46|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|436.92||||436.92|301.47|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92|301.47|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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|436.92||||436.92|87.38|332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|TML [1980]|TML [198000]|436.92||||436.92|301.47|332.06|87.38
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]|436.92||||436.92|170.05|332.06|87.38
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]|436.92||||436.92||332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UNICARE [2040]|UNICARE [204000]|436.92||||436.92||332.06|87.38
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]|436.92||||436.92||332.06|87.38
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|WEB TPA [2115]|WEB TPA [211500]|436.92||||436.92|301.47|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|436.92||||436.92|0|332.06|87.38
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]|TML WC [212537]|436.92||||436.92||332.06|87.38
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|20.86||||20.86|10.43|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMBETTER [2930]|AMBETTER [293000]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.86||||20.86|0.82|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.86||||20.86|8.12|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|15.02|15.85|0.82
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]|20.86||||20.86|10.43|15.85|0.82
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]|20.86||||20.86|10.43|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.86||||20.86|15.85|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.86||||20.86|14.39|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA PPO [126025]|20.86||||20.86|8.34|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.86||||20.86|10.43|15.85|0.82
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]|20.86||||20.86|14.39|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.86||||20.86|0.82|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.86||||20.86|14.39|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.86||||20.86|14.39|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|Self-pay|Self-pay|20.86||||20.86|4.17|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|TML [1980]|TML [198000]|20.86||||20.86|14.39|15.85|0.82
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]|20.86||||20.86|8.12|15.85|0.82
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]|20.86||||20.86|10.43|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNICARE [2040]|UNICARE [204000]|20.86||||20.86|10.43|15.85|0.82
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]|20.86||||20.86|10.43|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WEB TPA [2115]|WEB TPA [211500]|20.86||||20.86|14.39|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
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]|20.86||||20.86|0|15.85|0.82
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TML WC [212537]|20.86||||20.86|10.43|15.85|0.82
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AARP [1000]|AARP [100000]|0.27||||0.27||0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AETNA [1015]|AETNA [101529]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AMBETTER [2930]|AMBETTER [293000]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.27||||0.27|0.14|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.14|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.27||||0.27|0.21|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.27||||0.27||0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.27||||0.27|0.14|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|Self-pay|Self-pay|0.27||||0.27|0.05|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|TML [1980]|TML [198000]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.11|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|UNICARE [2040]|UNICARE [204000]|0.27||||0.27||0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|WEB TPA [2115]|WEB TPA [211500]|0.27||||0.27|0.19|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27|0|0.21|0.05
40848639|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN A 10,000 UNIT CAPSULE WRAP RECORD|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|0.27||||0.27||0.21|0.05
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AARP [1000]|AARP [100000]|40.8||||40.8|20.4|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AETNA [1015]|AETNA [101529]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40.8||||40.8|6.94|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40.8||||40.8|15.88|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|29.38|31.01|6.94
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]|40.8||||40.8|20.4|31.01|6.94
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]|40.8||||40.8|20.4|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40.8||||40.8|31.01|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40.8||||40.8|28.15|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|40.8||||40.8|16.32|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40.8||||40.8|20.4|31.01|6.94
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]|40.8||||40.8|28.15|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40.8||||40.8|6.94|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40.8||||40.8|28.15|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|40.8||||40.8|28.15|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|Self-pay|Self-pay|40.8||||40.8|8.16|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|TML [1980]|TML [198000]|40.8||||40.8|28.15|31.01|6.94
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]|40.8||||40.8|15.88|31.01|6.94
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]|40.8||||40.8|20.4|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNICARE [2040]|UNICARE [204000]|40.8||||40.8|20.4|31.01|6.94
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]|40.8||||40.8|20.4|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|40.8||||40.8|28.15|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
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]|40.8||||40.8|0|31.01|6.94
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|40.8||||40.8|20.4|31.01|6.94
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|14.74||||14.74|7.37|11.2|1.4
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]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.74||||14.74|5.74|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.74||||14.74|1.4|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.74||||14.74|5.74|11.2|1.4
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]|14.74||||14.74|0|11.2|1.4
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]|14.74||||14.74|10.61|11.2|1.4
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]|14.74||||14.74|7.37|11.2|1.4
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]|14.74||||14.74|7.37|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.74||||14.74|11.2|11.2|1.4
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]|14.74||||14.74|5.74|11.2|1.4
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]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.74||||14.74|10.17|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.74||||14.74|5.9|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.74||||14.74|7.37|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.74||||14.74|10.17|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.74||||14.74|1.4|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.74||||14.74|10.17|11.2|1.4
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]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.74||||14.74|5.74|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.74||||14.74|0|11.2|1.4
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]|14.74||||14.74|5.74|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.74||||14.74|10.17|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.74||||14.74|5.74|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|Self-pay|Self-pay|14.74||||14.74|2.95|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|TML [1980]|TML [198000]|14.74||||14.74|10.17|11.2|1.4
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]|14.74||||14.74|5.74|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.74||||14.74|7.37|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNICARE [2040]|UNICARE [204000]|14.74||||14.74|7.37|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.74||||14.74|7.37|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.74||||14.74|10.17|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.74||||14.74|0|11.2|1.4
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]|14.74||||14.74|0|11.2|1.4
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.74||||14.74|7.37|11.2|1.4
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|37.89||||37.89|18.95|28.8|4.1
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]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMBETTER [2930]|AMBETTER [293000]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.89||||37.89|14.75|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.89||||37.89|4.1|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.89||||37.89|14.75|28.8|4.1
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]|37.89||||37.89|0|28.8|4.1
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]|37.89||||37.89|27.28|28.8|4.1
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]|37.89||||37.89|18.95|28.8|4.1
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]|37.89||||37.89|18.95|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.89||||37.89|28.8|28.8|4.1
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]|37.89||||37.89|14.75|28.8|4.1
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]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.89||||37.89|26.14|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA PPO [126025]|37.89||||37.89|15.16|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.89||||37.89|18.95|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.89||||37.89|26.14|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.89||||37.89|4.1|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.89||||37.89|26.14|28.8|4.1
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]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.89||||37.89|14.75|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.89||||37.89|0|28.8|4.1
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]|37.89||||37.89|14.75|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.89||||37.89|26.14|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.89||||37.89|14.75|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|37.89||||37.89|7.58|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|TML [1980]|TML [198000]|37.89||||37.89|26.14|28.8|4.1
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]|37.89||||37.89|14.75|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.89||||37.89|18.95|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNICARE [2040]|UNICARE [204000]|37.89||||37.89|18.95|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.89||||37.89|18.95|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WEB TPA [2115]|WEB TPA [211500]|37.89||||37.89|26.14|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.89||||37.89|0|28.8|4.1
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]|37.89||||37.89|0|28.8|4.1
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TML WC [212537]|37.89||||37.89|18.95|28.8|4.1
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AARP [1000]|AARP [100000]|5.28||||5.28||4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AETNA [1015]|AETNA [101529]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|3.8|4.01|1.06
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]|5.28||||5.28|2.64|4.01|1.06
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]|5.28||||5.28|2.64|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|4.01|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28||4.01|1.06
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]|5.28||||5.28|3.64|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|Self-pay|Self-pay|5.28||||5.28|1.06|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|TML [1980]|TML [198000]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|2.05|4.01|1.06
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]|5.28||||5.28||4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNICARE [2040]|UNICARE [204000]|5.28||||5.28||4.01|1.06
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]|5.28||||5.28||4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
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]|5.28||||5.28|0|4.01|1.06
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28||4.01|1.06
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AARP [1000]|AARP [100000]|253.18||||253.18|126.59|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AETNA [1015]|AETNA [101529]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AMBETTER [2930]|AMBETTER [293000]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|253.18||||253.18|98.54|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|253.18||||253.18|98.54|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
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]|253.18||||253.18|182.29|192.42|50.64
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]|253.18||||253.18|126.59|192.42|50.64
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]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|253.18||||253.18|192.42|192.42|50.64
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]|253.18||||253.18|98.54|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|253.18||||253.18|174.69|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|CIGNA [1260]|CIGNA PPO [126025]|253.18||||253.18|101.27|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|253.18||||253.18|174.69|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|253.18||||253.18|174.69|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|253.18||||253.18|0|192.42|50.64
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]|253.18||||253.18|98.54|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|253.18||||253.18|0|192.42|50.64
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]|253.18||||253.18|98.54|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|253.18||||253.18|174.69|192.42|50.64
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]|253.18||||253.18|98.54|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|Self-pay|Self-pay|253.18||||253.18|50.64|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|TML [1980]|TML [198000]|253.18||||253.18|174.69|192.42|50.64
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]|253.18||||253.18|98.54|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UNICARE [2040]|UNICARE [204000]|253.18||||253.18|126.59|192.42|50.64
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]|253.18||||253.18|126.59|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|WEB TPA [2115]|WEB TPA [211500]|253.18||||253.18|174.69|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
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]|253.18||||253.18|0|192.42|50.64
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|WORKER'S COMP [2125]|TML WC [212537]|253.18||||253.18|126.59|192.42|50.64
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]|28.32||||28.32||21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMBETTER [2930]|AMBETTER [293000]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|28.32||||28.32|14.16|21.52|5.66
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 MEDICAID [1165]|BCBS MEDICAID [116504]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|20.39|21.52|5.66
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]|28.32||||28.32|14.16|21.52|5.66
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]|28.32||||28.32|14.16|21.52|5.66
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 TRADITIONAL OF TEXAS [115503]|28.32||||28.32|21.52|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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 - GREAT WEST [126009]|28.32||||28.32|19.54|21.52|5.66
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 PPO [126025]|28.32||||28.32|11.33|21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|28.32||||28.32||21.52|5.66
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]|28.32||||28.32|19.54|21.52|5.66
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|28.32||||28.32|14.16|21.52|5.66
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|28.32||||28.32|19.54|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32|19.54|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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|28.32||||28.32|5.66|21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|TML [1980]|TML [198000]|28.32||||28.32|19.54|21.52|5.66
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]|28.32||||28.32|11.02|21.52|5.66
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]|28.32||||28.32||21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNICARE [2040]|UNICARE [204000]|28.32||||28.32||21.52|5.66
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]|28.32||||28.32||21.52|5.66
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WEB TPA [2115]|WEB TPA [211500]|28.32||||28.32|19.54|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|28.32||||28.32|0|21.52|5.66
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]|TML WC [212537]|28.32||||28.32||21.52|5.66
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|272.75|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|32.07|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|196.38|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|136.38|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|136.38|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|207.29|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|272.75|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|32.07|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|106.15|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|272.75|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|272.75|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|272.75|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75|0|272.75|32.07
41000237|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC RESPIRATORY STRENGTHING 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AARP [1000]|AARP [100000]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AETNA [1015]|AETNA [101529]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|272.75||||272.75|32.07|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.75||||272.75|196.38|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.75||||272.75|136.38|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.75||||272.75|136.38|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|272.75||||272.75|207.29|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|272.75||||272.75|109.1|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|272.75||||272.75|32.07|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|Self-pay|Self-pay|272.75||||272.75|54.55|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|TML [1980]|TML [198000]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.75||||272.75|106.15|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UNICARE [2040]|UNICARE [204000]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.75||||272.75|272.75|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|272.75||||272.75|188.2|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.75||||272.75|0|272.75|32.07
41000238|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC EDUC & BREATHING RETRAIN 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|272.75||||272.75|272.75|272.75|32.07
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|1.18||||1.18||0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.18||||1.18|0.59|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.85|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.59|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.18||||1.18|0.9|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|1.18||||1.18|0.47|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.18||||1.18||0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.18||||1.18|0.59|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|1.18||||1.18|0.24|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.46|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|1.18||||1.18||0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|1.18||||1.18|0.81|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18|0|0.9|0.24
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|1.18||||1.18||0.9|0.24
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AARP [1000]|AARP [100000]|590||||590|297|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA [1015]|AETNA [101529]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMBETTER [2930]|AMBETTER [293000]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|590||||590|343.79|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|590||||590|424.8|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|590||||590|295|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|590||||590|295|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|590||||590|448.4|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA [1260]|CIGNA PPO [126025]|590||||590|236|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|590||||590|297|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|590||||590|343.79|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|Self-pay|Self-pay|590||||590|118|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|TML [1980]|TML [198000]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|590||||590|229.63|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|590||||590|297|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNICARE [2040]|UNICARE [204000]|590||||590|297|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|590||||590|297|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WEB TPA [2115]|WEB TPA [211500]|590||||590|407.1|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|590||||590|0|448.4|118
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WORKER'S COMP [2125]|TML WC [212537]|590||||590|297|448.4|118
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AARP [1000]|AARP [100000]|10634||||10634|297|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AETNA [1015]|AETNA [101529]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AMBETTER [2930]|AMBETTER [293000]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10634||||10634|630.84|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10634||||10634|7656.48|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10634||||10634|5317|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10634||||10634|5317|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10634||||10634|8081.84|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA [1260]|CIGNA PPO [126025]|10634||||10634|4253.6|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10634||||10634|297|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10634||||10634|630.84|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|Self-pay|Self-pay|10634||||10634|2126.8|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|TML [1980]|TML [198000]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10634||||10634|4138.75|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10634||||10634|297|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UNICARE [2040]|UNICARE [204000]|10634||||10634|297|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10634||||10634|297|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WEB TPA [2115]|WEB TPA [211500]|10634||||10634|7337.46|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10634||||10634|0|8081.84|297
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WORKER'S COMP [2125]|TML WC [212537]|10634||||10634|297|8081.84|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AARP [1000]|AARP [100000]|8862||||8862|297|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AETNA [1015]|AETNA [101529]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AMBETTER [2930]|AMBETTER [293000]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8862||||8862|630.84|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8862||||8862|6380.64|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8862||||8862|4431|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8862||||8862|4431|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8862||||8862|6735.12|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA [1260]|CIGNA PPO [126025]|8862||||8862|3544.8|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8862||||8862|297|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8862||||8862|630.84|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|Self-pay|Self-pay|8862||||8862|1772.4|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|TML [1980]|TML [198000]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8862||||8862|3449.09|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8862||||8862|297|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UNICARE [2040]|UNICARE [204000]|8862||||8862|297|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8862||||8862|297|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WEB TPA [2115]|WEB TPA [211500]|8862||||8862|6114.78|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8862||||8862|0|6735.12|297
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WORKER'S COMP [2125]|TML WC [212537]|8862||||8862|297|6735.12|297
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AARP [1000]|AARP [100000]|398||||398|297|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA [1015]|AETNA [101529]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMBETTER [2930]|AMBETTER [293000]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|398||||398|244.24|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|398||||398|286.56|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|398||||398|199|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|398||||398|199|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|398||||398|302.48|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA [1260]|CIGNA PPO [126025]|398||||398|159.2|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|398||||398|297|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|398||||398|244.24|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|Self-pay|Self-pay|398||||398|79.6|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|TML [1980]|TML [198000]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|398||||398|154.9|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|398||||398|297|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNICARE [2040]|UNICARE [204000]|398||||398|297|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|398||||398|297|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WEB TPA [2115]|WEB TPA [211500]|398||||398|274.62|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|398||||398|0|302.48|79.6
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WORKER'S COMP [2125]|TML WC [212537]|398||||398|297|302.48|79.6
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AARP [1000]|AARP [100000]|664||||664|297|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA [1015]|AETNA [101529]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMBETTER [2930]|AMBETTER [293000]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|664||||664|244.24|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|664||||664|478.08|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|664||||664|332|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|664||||664|332|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|664||||664|504.64|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA [1260]|CIGNA PPO [126025]|664||||664|265.6|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|664||||664|297|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|664||||664|244.24|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|Self-pay|Self-pay|664||||664|132.8|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|TML [1980]|TML [198000]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|664||||664|258.43|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|664||||664|297|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNICARE [2040]|UNICARE [204000]|664||||664|297|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|664||||664|297|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WEB TPA [2115]|WEB TPA [211500]|664||||664|458.16|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|664||||664|0|504.64|132.8
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WORKER'S COMP [2125]|TML WC [212537]|664||||664|297|504.64|132.8
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AARP [1000]|AARP [100000]|4162||||4162|297|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA [1015]|AETNA [101529]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMBETTER [2930]|AMBETTER [293000]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4162||||4162|244.24|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4162||||4162|2996.64|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4162||||4162|2081|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4162||||4162|2081|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4162||||4162|3163.12|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA [1260]|CIGNA PPO [126025]|4162||||4162|1664.8|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4162||||4162|297|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4162||||4162|244.24|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|Self-pay|Self-pay|4162||||4162|832.4|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|TML [1980]|TML [198000]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4162||||4162|1619.85|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4162||||4162|297|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNICARE [2040]|UNICARE [204000]|4162||||4162|297|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4162||||4162|297|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WEB TPA [2115]|WEB TPA [211500]|4162||||4162|2871.78|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4162||||4162|0|3163.12|244.24
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WORKER'S COMP [2125]|TML WC [212537]|4162||||4162|297|3163.12|244.24
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AARP [1000]|AARP [100000]|146||||146|146|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA [1015]|AETNA [101529]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMBETTER [2930]|AMBETTER [293000]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|244.24|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146|56.82|244.24|29.2
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]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|105.12|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|73|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|110.96|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|58.4|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146|146|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|244.24|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|244.24|29.2
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]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|0|244.24|29.2
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]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|Self-pay|Self-pay|146||||146|29.2|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|TML [1980]|TML [198000]|146||||146|100.74|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|56.82|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146|146|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNICARE [2040]|UNICARE [204000]|146||||146|146|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146|146|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|0|244.24|29.2
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]|146||||146|0|244.24|29.2
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146|146|244.24|29.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AARP [1000]|AARP [100000]|346||||346|297|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA [1015]|AETNA [101529]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMBETTER [2930]|AMBETTER [293000]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|346||||346|145.54|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|346||||346|249.12|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|346||||346|173|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|346||||346|173|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|346||||346|262.96|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA [1260]|CIGNA PPO [126025]|346||||346|138.4|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|346||||346|297|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|346||||346|145.54|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|Self-pay|Self-pay|346||||346|69.2|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|TML [1980]|TML [198000]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|346||||346|134.66|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|346||||346|297|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNICARE [2040]|UNICARE [204000]|346||||346|297|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|346||||346|297|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WEB TPA [2115]|WEB TPA [211500]|346||||346|238.74|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|346||||346|0|297|69.2
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WORKER'S COMP [2125]|TML WC [212537]|346||||346|297|297|69.2
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AARP [1000]|AARP [100000]|324||||324|297|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AETNA [1015]|AETNA [101529]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AMBETTER [2930]|AMBETTER [293000]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|324||||324|145.54|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324||||324|233.28|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324||||324|162|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324||||324|162|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|324||||324|246.24|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA [1260]|CIGNA PPO [126025]|324||||324|129.6|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|324||||324|297|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|324||||324|145.54|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|Self-pay|Self-pay|324||||324|64.8|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|TML [1980]|TML [198000]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324||||324|126.1|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324||||324|297|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UNICARE [2040]|UNICARE [204000]|324||||324|297|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324||||324|297|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WEB TPA [2115]|WEB TPA [211500]|324||||324|223.56|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324||||324|0|297|64.8
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WORKER'S COMP [2125]|TML WC [212537]|324||||324|297|297|64.8
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|1234.2||||1234.2||937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMBETTER [2930]|AMBETTER [293000]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1234.2||||1234.2|1.42|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1234.2||||1234.2|888.62|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1234.2||||1234.2|617.1|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1234.2||||1234.2|617.1|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1234.2||||1234.2|937.99|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|1234.2||||1234.2|493.68|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1234.2||||1234.2||937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1234.2||||1234.2|1.42|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|1234.2||||1234.2|246.84|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|TML [1980]|TML [198000]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1234.2||||1234.2|480.35|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1234.2||||1234.2||937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNICARE [2040]|UNICARE [204000]|1234.2||||1234.2||937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1234.2||||1234.2||937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WEB TPA [2115]|WEB TPA [211500]|1234.2||||1234.2|851.6|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1234.2||||1234.2|0|937.99|1.42
41144|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|1234.2||||1234.2||937.99|1.42
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AARP [1000]|AARP [100000]|1704||||1704|739|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AETNA [1015]|AETNA [101529]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMBETTER [2930]|AMBETTER [293000]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1704||||1704|155.06|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1704||||1704|1226.88|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1704||||1704|852|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1704||||1704|852|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1704||||1704|1295.04|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|CIGNA [1260]|CIGNA PPO [126025]|1704||||1704|681.6|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1704||||1704|739|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1704||||1704|155.06|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|Self-pay|Self-pay|1704||||1704|340.8|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|TML [1980]|TML [198000]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1704||||1704|663.2|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1704||||1704|739|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UNICARE [2040]|UNICARE [204000]|1704||||1704|739|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1704||||1704|739|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WEB TPA [2115]|WEB TPA [211500]|1704||||1704|1175.76|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1704||||1704|0|1295.04|155.06
41300277|EAP|0413 - RESPIRATORY SERVICES-HYPERBARIC OXYGEN THER|HC HYPERBARC O2 FULL BDY THPY 30M|1|WORKER'S COMP [2125]|TML WC [212537]|1704||||1704|739|1295.04|155.06
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|214.4||||214.4||162.94|42.88
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]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.4||||214.4|83.44|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|214.4||||214.4|107.2|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|214.4||||214.4|83.44|162.94|42.88
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]|214.4||||214.4|0|162.94|42.88
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]|214.4||||214.4|154.37|162.94|42.88
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]|214.4||||214.4|107.2|162.94|42.88
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]|214.4||||214.4|107.2|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|214.4||||214.4|162.94|162.94|42.88
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]|214.4||||214.4|83.44|162.94|42.88
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]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|214.4||||214.4|147.94|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|214.4||||214.4|85.76|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|214.4||||214.4||162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|214.4||||214.4|147.94|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|214.4||||214.4|107.2|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|214.4||||214.4|147.94|162.94|42.88
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]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.4||||214.4|83.44|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.4||||214.4|0|162.94|42.88
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]|214.4||||214.4|83.44|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|214.4||||214.4|147.94|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.4||||214.4|83.44|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|214.4||||214.4|42.88|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|214.4||||214.4|147.94|162.94|42.88
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]|214.4||||214.4|83.44|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.4||||214.4||162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|214.4||||214.4||162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.4||||214.4||162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|214.4||||214.4|147.94|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.4||||214.4|0|162.94|42.88
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]|214.4||||214.4|0|162.94|42.88
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|214.4||||214.4||162.94|42.88
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AARP [1000]|AARP [100000]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA [1015]|AETNA [101529]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMBETTER [2930]|AMBETTER [293000]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.7||||10.7|5.35|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.7||||10.7|4.16|12.65|2.14
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]|10.7||||10.7|0|12.65|2.14
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]|10.7||||10.7|7.7|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.7||||10.7|5.35|12.65|2.14
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]|10.7||||10.7|5.35|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.7||||10.7|8.13|12.65|2.14
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]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.7||||10.7|7.38|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA [1260]|CIGNA PPO [126025]|10.7||||10.7|4.28|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.7||||10.7|7.38|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.7||||10.7|5.35|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.7||||10.7|7.38|12.65|2.14
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]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.7||||10.7|0|12.65|2.14
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]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.7||||10.7|7.38|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|Self-pay|Self-pay|10.7||||10.7|2.14|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|TML [1980]|TML [198000]|10.7||||10.7|7.38|12.65|2.14
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]|10.7||||10.7|4.16|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNICARE [2040]|UNICARE [204000]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WEB TPA [2115]|WEB TPA [211500]|10.7||||10.7|7.38|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.7||||10.7|0|12.65|2.14
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]|10.7||||10.7|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WORKER'S COMP [2125]|TML WC [212537]|10.7||||10.7||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AARP [1000]|AARP [100000]|16.64||||16.64||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA [1015]|AETNA [101529]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMBETTER [2930]|AMBETTER [293000]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|16.64||||16.64|8.32|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|16.64||||16.64|6.48|12.65|2.14
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]|16.64||||16.64|0|12.65|2.14
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]|16.64||||16.64|11.98|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.64||||16.64|8.32|12.65|2.14
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]|16.64||||16.64|8.32|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|16.64||||16.64|12.65|12.65|2.14
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]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|16.64||||16.64|11.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA [1260]|CIGNA PPO [126025]|16.64||||16.64|6.66|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|16.64||||16.64||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.64||||16.64|11.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|16.64||||16.64|8.32|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|16.64||||16.64|11.48|12.65|2.14
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]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.64||||16.64|0|12.65|2.14
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]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.64||||16.64|11.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|Self-pay|Self-pay|16.64||||16.64|3.33|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|TML [1980]|TML [198000]|16.64||||16.64|11.48|12.65|2.14
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]|16.64||||16.64|6.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.64||||16.64||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNICARE [2040]|UNICARE [204000]|16.64||||16.64||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.64||||16.64||12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WEB TPA [2115]|WEB TPA [211500]|16.64||||16.64|11.48|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.64||||16.64|0|12.65|2.14
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]|16.64||||16.64|0|12.65|2.14
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WORKER'S COMP [2125]|TML WC [212537]|16.64||||16.64||12.65|2.14
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|13.2||||13.2||10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|13.2||||13.2|6.6|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.2||||13.2|9.5|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.2||||13.2|6.6|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.2||||13.2|6.6|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|13.2||||13.2|10.03|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|13.2||||13.2|5.28|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|13.2||||13.2||10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|13.2||||13.2|6.6|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|Self-pay|Self-pay|13.2||||13.2|2.64|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.2||||13.2|5.14|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.2||||13.2||10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|13.2||||13.2||10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.2||||13.2||10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|13.2||||13.2|9.11|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.2||||13.2|0|10.03|2.64
41497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PARICALCITOL 1 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|13.2||||13.2||10.03|2.64
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AARP [1000]|AARP [100000]|572.6||||572.6||435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AETNA [1015]|AETNA [101529]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AMBETTER [2930]|AMBETTER [293000]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|572.6||||572.6|286.3|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|572.6||||572.6|222.86|435.18|114.52
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]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|572.6||||572.6|412.27|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|572.6||||572.6|286.3|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|572.6||||572.6|286.3|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|572.6||||572.6|435.18|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|572.6||||572.6|395.09|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA [1260]|CIGNA PPO [126025]|572.6||||572.6|229.04|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|572.6||||572.6||435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|GROUP PENSION ADMIN [1450]|GPA [145000]|572.6||||572.6|395.09|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|572.6||||572.6|286.3|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|572.6||||572.6|395.09|435.18|114.52
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]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|572.6||||572.6|0|435.18|114.52
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]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|PHCS [1780]|PHCS MULTIPLAN [178000]|572.6||||572.6|395.09|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|Self-pay|Self-pay|572.6||||572.6|114.52|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|TML [1980]|TML [198000]|572.6||||572.6|395.09|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|572.6||||572.6|222.86|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|572.6||||572.6||435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UNICARE [2040]|UNICARE [204000]|572.6||||572.6||435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|572.6||||572.6||435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|WEB TPA [2115]|WEB TPA [211500]|572.6||||572.6|395.09|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|572.6||||572.6|0|435.18|114.52
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]|572.6||||572.6|0|435.18|114.52
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|WORKER'S COMP [2125]|TML WC [212537]|572.6||||572.6||435.18|114.52
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.34||||15.34||11.66|3.07
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]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.34||||15.34|5.97|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.34||||15.34|7.67|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.34||||15.34|5.97|11.66|3.07
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]|15.34||||15.34|0|11.66|3.07
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]|15.34||||15.34|11.04|11.66|3.07
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]|15.34||||15.34|7.67|11.66|3.07
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]|15.34||||15.34|7.67|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.34||||15.34|11.66|11.66|3.07
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]|15.34||||15.34|5.97|11.66|3.07
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]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.34||||15.34|10.58|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.34||||15.34|6.14|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.34||||15.34||11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.34||||15.34|10.58|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.34||||15.34|7.67|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.34||||15.34|10.58|11.66|3.07
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]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.34||||15.34|5.97|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.34||||15.34|0|11.66|3.07
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]|15.34||||15.34|5.97|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.34||||15.34|10.58|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.34||||15.34|5.97|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|Self-pay|Self-pay|15.34||||15.34|3.07|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.34||||15.34|10.58|11.66|3.07
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]|15.34||||15.34|5.97|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.34||||15.34||11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.34||||15.34||11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.34||||15.34||11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.34||||15.34|10.58|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.34||||15.34|0|11.66|3.07
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]|15.34||||15.34|0|11.66|3.07
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.34||||15.34||11.66|3.07
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AARP [1000]|AARP [100000]|128.25||||128.25|128.25|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AETNA [1015]|AETNA [101529]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMBETTER [2930]|AMBETTER [293000]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.25||||128.25|64.13|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.25||||128.25|92.34|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.25||||128.25|64.13|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.25||||128.25|64.13|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.25||||128.25|97.47|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|CIGNA [1260]|CIGNA PPO [126025]|128.25||||128.25|51.3|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.25||||128.25|128.25|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.25||||128.25|64.13|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|Self-pay|Self-pay|128.25||||128.25|25.65|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|TML [1980]|TML [198000]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.25||||128.25|49.91|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.25||||128.25|128.25|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNICARE [2040]|UNICARE [204000]|128.25||||128.25|128.25|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.25||||128.25|128.25|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WEB TPA [2115]|WEB TPA [211500]|128.25||||128.25|88.49|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.25||||128.25|0|128.25|25.65
42000283|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECT STIM UNATTEND NON WOUND|1|WORKER'S COMP [2125]|TML WC [212537]|128.25||||128.25|128.25|128.25|25.65
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AARP [1000]|AARP [100000]|321.5||||321.5|192|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AETNA [1015]|AETNA [101529]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMBETTER [2930]|AMBETTER [293000]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|321.5||||321.5|160.75|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|321.5||||321.5|231.48|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|321.5||||321.5|160.75|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|321.5||||321.5|160.75|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|321.5||||321.5|244.34|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|CIGNA [1260]|CIGNA PPO [126025]|321.5||||321.5|128.6|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|321.5||||321.5|192|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|321.5||||321.5|160.75|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|Self-pay|Self-pay|321.5||||321.5|64.3|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|TML [1980]|TML [198000]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|321.5||||321.5|125.13|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|321.5||||321.5|192|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UNICARE [2040]|UNICARE [204000]|321.5||||321.5|192|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|321.5||||321.5|192|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WEB TPA [2115]|WEB TPA [211500]|321.5||||321.5|221.84|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|321.5||||321.5|0|244.34|64.3
42095851|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ROM TEST EXCLUDING HAND|1|WORKER'S COMP [2125]|TML WC [212537]|321.5||||321.5|192|244.34|64.3
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AARP [1000]|AARP [100000]|171||||171|171|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA [1015]|AETNA [101529]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMBETTER [2930]|AMBETTER [293000]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|171||||171|85.5|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171||||171|123.12|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171||||171|85.5|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171||||171|85.5|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|171||||171|129.96|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA [1260]|CIGNA PPO [126025]|171||||171|68.4|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|171||||171|171|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|171||||171|85.5|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|Self-pay|Self-pay|171||||171|34.2|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|TML [1980]|TML [198000]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171||||171|66.55|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171||||171|171|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNICARE [2040]|UNICARE [204000]|171||||171|171|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171||||171|171|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WEB TPA [2115]|WEB TPA [211500]|171||||171|117.99|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171||||171|0|171|34.2
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WORKER'S COMP [2125]|TML WC [212537]|171||||171|171|171|34.2
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AARP [1000]|AARP [100000]|193.25||||193.25|192|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA [1015]|AETNA [101529]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.25||||193.25|96.63|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193.25||||193.25|139.14|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193.25||||193.25|96.63|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193.25||||193.25|96.63|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.25||||193.25|146.87|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|193.25||||193.25|77.3|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.25||||193.25|192|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.25||||193.25|96.63|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|Self-pay|Self-pay|193.25||||193.25|38.65|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|TML [1980]|TML [198000]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193.25||||193.25|75.21|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.25||||193.25|192|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNICARE [2040]|UNICARE [204000]|193.25||||193.25|192|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.25||||193.25|192|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|193.25||||193.25|133.34|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193.25||||193.25|0|192|38.65
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AARP [1000]|AARP [100000]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA [1015]|AETNA [101529]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.25||||193.25|96.63|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193.25||||193.25|139.14|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193.25||||193.25|96.63|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193.25||||193.25|96.63|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.25||||193.25|146.87|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|193.25||||193.25|77.3|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.25||||193.25|96.63|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|Self-pay|Self-pay|193.25||||193.25|38.65|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|TML [1980]|TML [198000]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193.25||||193.25|75.21|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.25||||193.25|192|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|193.25||||193.25|133.34|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193.25||||193.25|0|192|38.65
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|193.25||||193.25|192|192|38.65
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|149.5||||149.5|149.5|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.5||||149.5|74.75|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.5||||149.5|107.64|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.5||||149.5|74.75|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.5||||149.5|74.75|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.5||||149.5|113.62|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|149.5||||149.5|59.8|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.5||||149.5|149.5|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.5||||149.5|74.75|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|Self-pay|Self-pay|149.5||||149.5|29.9|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|TML [1980]|TML [198000]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.5||||149.5|58.19|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.5||||149.5|149.5|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|149.5||||149.5|149.5|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.5||||149.5|149.5|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|149.5||||149.5|103.16|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.5||||149.5|0|149.5|29.9
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|149.5||||149.5|149.5|149.5|29.9
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AARP [1000]|AARP [100000]|300||||300|192|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AETNA [1015]|AETNA [101529]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|300||||300|150|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|216|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|150|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|300||||300|228|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|300||||300|120|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|300||||300|192|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|300||||300|150|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|Self-pay|Self-pay|300||||300|60|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|TML [1980]|TML [198000]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|116.76|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|192|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNICARE [2040]|UNICARE [204000]|300||||300|192|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|192|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|300||||300|207|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300|0|228|60
42097113|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC AQUATIC THERAPY/EXERCISE 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|300||||300|192|228|60
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|249.48||||249.48|192|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|249.48||||249.48|124.74|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|249.48||||249.48|179.63|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|249.48||||249.48|124.74|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|249.48||||249.48|124.74|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|249.48||||249.48|189.6|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|249.48||||249.48|99.79|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|249.48||||249.48|192|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|249.48||||249.48|124.74|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|249.48||||249.48|49.9|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TML [1980]|TML [198000]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|249.48||||249.48|97.1|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|249.48||||249.48|192|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|249.48||||249.48|192|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|249.48||||249.48|192|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|249.48||||249.48|172.14|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|249.48||||249.48|0|192|49.9
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|249.48||||249.48|192|192|49.9
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|257.5||||257.5|192|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|257.5||||257.5|128.75|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|257.5||||257.5|185.4|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|257.5||||257.5|128.75|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|257.5||||257.5|128.75|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|257.5||||257.5|195.7|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|257.5||||257.5|103|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|257.5||||257.5|192|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|257.5||||257.5|128.75|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|257.5||||257.5|51.5|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TML [1980]|TML [198000]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|257.5||||257.5|100.22|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|257.5||||257.5|192|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|257.5||||257.5|192|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|257.5||||257.5|192|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|257.5||||257.5|177.68|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|257.5||||257.5|0|195.7|51.5
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|257.5||||257.5|192|195.7|51.5
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AARP [1000]|AARP [100000]|96||||96|96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA [1015]|AETNA [101529]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|96||||96|48|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|69.12|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|48|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|48|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|96||||96|72.96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|96||||96|38.4|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|96||||96|96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|96||||96|48|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|Self-pay|Self-pay|96||||96|19.2|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|TML [1980]|TML [198000]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96|37.36|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96|96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNICARE [2040]|UNICARE [204000]|96||||96|96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96|96|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|96||||96|66.24|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96|0|96|19.2
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|96||||96|96|96|19.2
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AARP [1000]|AARP [100000]|218.75||||218.75|192|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA [1015]|AETNA [101529]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|218.75||||218.75|109.38|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|218.75||||218.75|157.5|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|218.75||||218.75|109.38|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|218.75||||218.75|109.38|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|218.75||||218.75|166.25|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|218.75||||218.75|87.5|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|218.75||||218.75|192|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|218.75||||218.75|109.38|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|Self-pay|Self-pay|218.75||||218.75|43.75|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|TML [1980]|TML [198000]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|218.75||||218.75|85.14|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|218.75||||218.75|192|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNICARE [2040]|UNICARE [204000]|218.75||||218.75|192|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|218.75||||218.75|192|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|218.75||||218.75|150.94|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|218.75||||218.75|0|192|43.75
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|218.75||||218.75|192|192|43.75
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|235.75||||235.75|192|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|235.75||||235.75|117.88|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235.75||||235.75|169.74|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235.75||||235.75|117.88|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235.75||||235.75|117.88|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|235.75||||235.75|179.17|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|235.75||||235.75|94.3|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|235.75||||235.75|192|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|235.75||||235.75|117.88|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|235.75||||235.75|47.15|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|TML [1980]|TML [198000]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235.75||||235.75|91.75|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235.75||||235.75|192|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|235.75||||235.75|192|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235.75||||235.75|192|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|235.75||||235.75|162.67|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235.75||||235.75|0|192|47.15
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]|235.75||||235.75|0|192|47.15
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|235.75||||235.75|192|192|47.15
4210001|EAP||HH PT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|100.61|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|69.87|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|106.19|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|27.95|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73|0|106.19|27.95
4210001|EAP||HH PT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|100.61|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|69.87|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|106.19|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|Self-pay|Self-pay|||||139.73|27.95|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|TML [1980]|TML [198000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73|0|106.19|27.95
4210002|EAP||HH PT INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|100.61|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|69.87|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|106.19|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|27.95|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|TML [1980]|TML [198000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73|0|106.19|27.95
4210003|EAP||HH PTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|100.61|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|69.87|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||139.73|106.19|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|Self-pay|Self-pay|||||139.73|27.95|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|TML [1980]|TML [198000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73|0|106.19|27.95
4210004|EAP||HH PT MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||139.73|0|106.19|27.95
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|113.35||||113.35||86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|113.35||||113.35|56.68|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|113.35||||113.35|44.12|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113.35||||113.35|81.61|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113.35||||113.35|56.68|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113.35||||113.35|56.68|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|113.35||||113.35|86.15|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|113.35||||113.35|78.21|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|113.35||||113.35|45.34|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|113.35||||113.35||86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|113.35||||113.35|78.21|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|113.35||||113.35|56.68|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|113.35||||113.35|78.21|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113.35||||113.35|0|86.15|22.67
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]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|113.35||||113.35|78.21|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|113.35||||113.35|22.67|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|113.35||||113.35|78.21|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113.35||||113.35|44.12|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113.35||||113.35||86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|113.35||||113.35||86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113.35||||113.35||86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|113.35||||113.35|78.21|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113.35||||113.35|0|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|113.35||||113.35|56.68|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|113.35||||113.35|44.12|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113.35||||113.35|81.61|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113.35||||113.35|56.68|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113.35||||113.35|56.68|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|113.35||||113.35|86.15|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|113.35||||113.35|78.21|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|113.35||||113.35|45.34|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|113.35||||113.35|78.21|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|113.35||||113.35|56.68|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|113.35||||113.35|78.21|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113.35||||113.35|0|86.15|22.67
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]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|113.35||||113.35|78.21|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|113.35||||113.35|22.67|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|113.35||||113.35|78.21|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113.35||||113.35|44.12|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113.35||||113.35||86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|113.35||||113.35|78.21|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113.35||||113.35|0|86.15|22.67
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]|113.35||||113.35|0|86.15|22.67
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|113.35||||113.35||86.15|22.67
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|17.79||||17.79||13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.79||||17.79|8.9|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.79||||17.79|6.92|13.52|3.56
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]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.79||||17.79|12.81|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.79||||17.79|8.9|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.79||||17.79|8.9|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.79||||17.79|13.52|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.79||||17.79|12.28|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|17.79||||17.79|7.12|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.79||||17.79||13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|17.79||||17.79|12.28|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.79||||17.79|8.9|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.79||||17.79|12.28|13.52|3.56
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]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.79||||17.79|0|13.52|3.56
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]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|17.79||||17.79|12.28|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|17.79||||17.79|3.56|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|17.79||||17.79|12.28|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.79||||17.79|6.92|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.79||||17.79||13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|17.79||||17.79||13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.79||||17.79||13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|17.79||||17.79|12.28|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.79||||17.79|0|13.52|3.56
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]|17.79||||17.79|0|13.52|3.56
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|17.79||||17.79||13.52|3.56
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|498.96||||498.96|192|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|498.96||||498.96|249.48|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|498.96||||498.96|359.25|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|498.96||||498.96|249.48|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|498.96||||498.96|249.48|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|498.96||||498.96|379.21|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|498.96||||498.96|199.58|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|498.96||||498.96|192|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|498.96||||498.96|249.48|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|498.96||||498.96|99.79|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|TML [1980]|TML [198000]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|498.96||||498.96|194.2|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|498.96||||498.96|192|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|498.96||||498.96|192|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|498.96||||498.96|192|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|498.96||||498.96|344.28|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|498.96||||498.96|0|379.21|99.79
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]|498.96||||498.96|0|379.21|99.79
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|498.96||||498.96|192|379.21|99.79
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|641.34||||641.34|192|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641.34||||641.34|320.67|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641.34||||641.34|461.76|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641.34||||641.34|320.67|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641.34||||641.34|320.67|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641.34||||641.34|487.42|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|641.34||||641.34|256.54|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641.34||||641.34|192|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641.34||||641.34|320.67|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|641.34||||641.34|128.27|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|TML [1980]|TML [198000]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641.34||||641.34|249.61|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641.34||||641.34|192|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|641.34||||641.34|192|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641.34||||641.34|192|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|641.34||||641.34|442.52|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641.34||||641.34|0|487.42|128.27
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]|641.34||||641.34|0|487.42|128.27
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|641.34||||641.34|192|487.42|128.27
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|783.72||||783.72|192|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.72||||783.72|391.86|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.72||||783.72|564.28|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.72||||783.72|391.86|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.72||||783.72|391.86|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.72||||783.72|595.63|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|783.72||||783.72|313.49|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.72||||783.72|192|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.72||||783.72|391.86|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|783.72||||783.72|156.74|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|TML [1980]|TML [198000]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.72||||783.72|305.02|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.72||||783.72|192|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|783.72||||783.72|192|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.72||||783.72|192|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|783.72||||783.72|540.77|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.72||||783.72|0|595.63|156.74
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]|783.72||||783.72|0|595.63|156.74
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|783.72||||783.72|192|595.63|156.74
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|277.2||||277.2|192|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|138.6|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|107.89|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|199.58|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|138.6|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|138.6|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|210.67|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2|192|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|138.6|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|0|210.67|55.44
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]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|277.2||||277.2|55.44|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|TML [1980]|TML [198000]|277.2||||277.2|191.27|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|107.89|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2|192|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNICARE [2040]|UNICARE [204000]|277.2||||277.2|192|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2|192|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2|0|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2|192|210.67|55.44
4300001|EAP||HH OT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|101.29|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|70.34|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|106.92|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|Self-pay|Self-pay|||||140.68|28.14|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|TML [1980]|TML [198000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68|0|106.92|28.14
4300001|EAP||HH OT MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|106.92|28.14
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AARP [1000]|AARP [100000]|149.5||||149.5|149.5|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA [1015]|AETNA [101529]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMBETTER [2930]|AMBETTER [293000]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.5||||149.5|74.75|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.5||||149.5|107.64|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.5||||149.5|74.75|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.5||||149.5|74.75|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.5||||149.5|113.62|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA PPO [126025]|149.5||||149.5|59.8|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.5||||149.5|149.5|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.5||||149.5|74.75|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|Self-pay|Self-pay|149.5||||149.5|29.9|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|TML [1980]|TML [198000]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.5||||149.5|58.19|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.5||||149.5|149.5|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNICARE [2040]|UNICARE [204000]|149.5||||149.5|149.5|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.5||||149.5|149.5|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WEB TPA [2115]|WEB TPA [211500]|149.5||||149.5|103.16|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.5||||149.5|0|149.5|29.9
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TML WC [212537]|149.5||||149.5|149.5|149.5|29.9
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AARP [1000]|AARP [100000]|171||||171|171|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA [1015]|AETNA [101529]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMBETTER [2930]|AMBETTER [293000]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|171||||171|85.5|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171||||171|123.12|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171||||171|85.5|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171||||171|85.5|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|171||||171|129.96|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA PPO [126025]|171||||171|68.4|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|171||||171|171|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|171||||171|85.5|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|Self-pay|Self-pay|171||||171|34.2|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|TML [1980]|TML [198000]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171||||171|66.55|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171||||171|171|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNICARE [2040]|UNICARE [204000]|171||||171|171|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171||||171|171|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WEB TPA [2115]|WEB TPA [211500]|171||||171|117.99|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171||||171|0|171|34.2
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TML WC [212537]|171||||171|171|171|34.2
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AARP [1000]|AARP [100000]|193.25||||193.25|192|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA [1015]|AETNA [101529]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMBETTER [2930]|AMBETTER [293000]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|193.25||||193.25|96.63|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193.25||||193.25|139.14|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193.25||||193.25|96.63|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193.25||||193.25|96.63|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|193.25||||193.25|146.87|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA PPO [126025]|193.25||||193.25|77.3|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|193.25||||193.25|192|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|193.25||||193.25|96.63|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|Self-pay|Self-pay|193.25||||193.25|38.65|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|TML [1980]|TML [198000]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193.25||||193.25|75.21|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193.25||||193.25|192|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNICARE [2040]|UNICARE [204000]|193.25||||193.25|192|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193.25||||193.25|192|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WEB TPA [2115]|WEB TPA [211500]|193.25||||193.25|133.34|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193.25||||193.25|0|192|38.65
43097032|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TML WC [212537]|193.25||||193.25|192|192|38.65
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AARP [1000]|AARP [100000]|149.5||||149.5|149.5|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA [1015]|AETNA [101529]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|149.5||||149.5|74.75|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.5||||149.5|107.64|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.5||||149.5|74.75|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.5||||149.5|74.75|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|149.5||||149.5|113.62|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|149.5||||149.5|59.8|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|149.5||||149.5|149.5|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|149.5||||149.5|74.75|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|Self-pay|Self-pay|149.5||||149.5|29.9|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|TML [1980]|TML [198000]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.5||||149.5|58.19|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.5||||149.5|149.5|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNICARE [2040]|UNICARE [204000]|149.5||||149.5|149.5|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.5||||149.5|149.5|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|149.5||||149.5|103.16|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.5||||149.5|0|149.5|29.9
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|149.5||||149.5|149.5|149.5|29.9
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|249.48||||249.48|192|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|249.48||||249.48|124.74|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|249.48||||249.48|179.63|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|249.48||||249.48|124.74|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|249.48||||249.48|124.74|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|249.48||||249.48|189.6|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|249.48||||249.48|99.79|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|249.48||||249.48|192|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|249.48||||249.48|124.74|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|249.48||||249.48|49.9|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TML [1980]|TML [198000]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|249.48||||249.48|97.1|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|249.48||||249.48|192|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|249.48||||249.48|192|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|249.48||||249.48|192|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|249.48||||249.48|172.14|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|249.48||||249.48|0|192|49.9
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|249.48||||249.48|192|192|49.9
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|257.5||||257.5|192|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|257.5||||257.5|128.75|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|257.5||||257.5|185.4|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|257.5||||257.5|128.75|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|257.5||||257.5|128.75|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|257.5||||257.5|195.7|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|257.5||||257.5|103|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|257.5||||257.5|192|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|257.5||||257.5|128.75|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|257.5||||257.5|51.5|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TML [1980]|TML [198000]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|257.5||||257.5|100.22|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|257.5||||257.5|192|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNICARE [2040]|UNICARE [204000]|257.5||||257.5|192|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|257.5||||257.5|192|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|257.5||||257.5|177.68|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|257.5||||257.5|0|195.7|51.5
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|257.5||||257.5|192|195.7|51.5
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AARP [1000]|AARP [100000]|204.12||||204.12|192|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AETNA [1015]|AETNA [101529]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|204.12||||204.12|102.06|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204.12||||204.12|146.97|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204.12||||204.12|102.06|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204.12||||204.12|102.06|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|204.12||||204.12|155.13|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|204.12||||204.12|81.65|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|204.12||||204.12|192|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|204.12||||204.12|102.06|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|Self-pay|Self-pay|204.12||||204.12|40.82|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|TML [1980]|TML [198000]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204.12||||204.12|79.44|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204.12||||204.12|192|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNICARE [2040]|UNICARE [204000]|204.12||||204.12|192|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204.12||||204.12|192|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|204.12||||204.12|140.84|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204.12||||204.12|0|192|40.82
43097533|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC SENSORY INTEG DIRECT 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|204.12||||204.12|192|192|40.82
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AARP [1000]|AARP [100000]|400.68||||400.68|192|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|400.68||||400.68|200.34|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.68||||400.68|288.49|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.68||||400.68|200.34|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.68||||400.68|200.34|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|400.68||||400.68|304.52|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|400.68||||400.68|160.27|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|400.68||||400.68|192|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|400.68||||400.68|200.34|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|Self-pay|Self-pay|400.68||||400.68|80.14|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|TML [1980]|TML [198000]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.68||||400.68|155.94|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.68||||400.68|192|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNICARE [2040]|UNICARE [204000]|400.68||||400.68|192|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.68||||400.68|192|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|400.68||||400.68|276.47|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.68||||400.68|0|304.52|80.14
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|400.68||||400.68|192|304.52|80.14
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|146||||146|146|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMBETTER [2930]|AMBETTER [293000]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|146||||146|73|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|146||||146|56.82|146|29.2
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]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|105.12|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|73|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|146||||146|110.96|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|146||||146|100.74|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|146||||146|58.4|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|146||||146|146|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|146||||146|73|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|146||||146|100.74|146|29.2
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]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|0|146|29.2
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]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|146||||146|29.2|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|TML [1980]|TML [198000]|146||||146|100.74|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|56.82|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146|146|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNICARE [2040]|UNICARE [204000]|146||||146|146|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146|146|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WEB TPA [2115]|WEB TPA [211500]|146||||146|100.74|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|0|146|29.2
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]|146||||146|0|146|29.2
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|146||||146|146|146|29.2
4310001|EAP||HH OT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|101.29|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|70.34|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|106.92|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|28.14|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68|0|106.92|28.14
4310001|EAP||HH OT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|101.29|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|70.34|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|106.92|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|Self-pay|Self-pay|||||140.68|28.14|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|TML [1980]|TML [198000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68|0|106.92|28.14
4310002|EAP||HH OT INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|101.29|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|70.34|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||140.68|106.92|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|28.14|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|TML [1980]|TML [198000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68|0|106.92|28.14
4310003|EAP||HH OTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||140.68|0|106.92|28.14
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|3.24|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|3.24|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|66||||66|13.2|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|33|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66|0|50.16|3.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|33|50.16|3.24
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|498.96||||498.96|192|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|498.96||||498.96|249.48|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|498.96||||498.96|359.25|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|498.96||||498.96|249.48|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|498.96||||498.96|249.48|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|498.96||||498.96|379.21|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|498.96||||498.96|199.58|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|498.96||||498.96|192|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|498.96||||498.96|249.48|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|498.96||||498.96|99.79|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|TML [1980]|TML [198000]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|498.96||||498.96|194.2|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|498.96||||498.96|192|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|498.96||||498.96|192|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|498.96||||498.96|192|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|498.96||||498.96|344.28|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|498.96||||498.96|0|379.21|99.79
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]|498.96||||498.96|0|379.21|99.79
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|498.96||||498.96|192|379.21|99.79
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|641.34||||641.34|192|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641.34||||641.34|320.67|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641.34||||641.34|461.76|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641.34||||641.34|320.67|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641.34||||641.34|320.67|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641.34||||641.34|487.42|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|641.34||||641.34|256.54|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641.34||||641.34|192|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641.34||||641.34|320.67|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|641.34||||641.34|128.27|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|TML [1980]|TML [198000]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641.34||||641.34|249.61|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641.34||||641.34|192|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|641.34||||641.34|192|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641.34||||641.34|192|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|641.34||||641.34|442.52|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641.34||||641.34|0|487.42|128.27
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]|641.34||||641.34|0|487.42|128.27
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|641.34||||641.34|192|487.42|128.27
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|783.72||||783.72|192|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMBETTER [2930]|AMBETTER [293000]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|783.72||||783.72|391.86|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.72||||783.72|564.28|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.72||||783.72|391.86|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.72||||783.72|391.86|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|783.72||||783.72|595.63|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA PPO [126025]|783.72||||783.72|313.49|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|783.72||||783.72|192|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|783.72||||783.72|391.86|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|783.72||||783.72|156.74|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|TML [1980]|TML [198000]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.72||||783.72|305.02|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.72||||783.72|192|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNICARE [2040]|UNICARE [204000]|783.72||||783.72|192|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.72||||783.72|192|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WEB TPA [2115]|WEB TPA [211500]|783.72||||783.72|540.77|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.72||||783.72|0|595.63|156.74
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]|783.72||||783.72|0|595.63|156.74
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TML WC [212537]|783.72||||783.72|192|595.63|156.74
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|277.2||||277.2|192|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMBETTER [2930]|AMBETTER [293000]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|277.2||||277.2|138.6|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|277.2||||277.2|107.89|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.2||||277.2|199.58|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.2||||277.2|138.6|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.2||||277.2|138.6|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|277.2||||277.2|210.67|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|277.2||||277.2|191.27|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA PPO [126025]|277.2||||277.2|110.88|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|277.2||||277.2|192|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.2||||277.2|191.27|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|277.2||||277.2|138.6|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|277.2||||277.2|191.27|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.2||||277.2|0|210.67|55.44
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]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.2||||277.2|191.27|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|277.2||||277.2|55.44|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|TML [1980]|TML [198000]|277.2||||277.2|191.27|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.2||||277.2|107.89|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.2||||277.2|192|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNICARE [2040]|UNICARE [204000]|277.2||||277.2|192|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.2||||277.2|192|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WEB TPA [2115]|WEB TPA [211500]|277.2||||277.2|191.27|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.2||||277.2|0|210.67|55.44
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]|277.2||||277.2|0|210.67|55.44
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TML WC [212537]|277.2||||277.2|192|210.67|55.44
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.78||||3.78||2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.78||||3.78|1.89|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.78||||3.78|1.47|2.87|0.76
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]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.78||||3.78|2.72|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.78||||3.78|1.89|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.78||||3.78|1.89|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.78||||3.78|2.87|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.78||||3.78|2.61|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.78||||3.78|1.51|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.78||||3.78||2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.78||||3.78|2.61|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.78||||3.78|1.89|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.78||||3.78|2.61|2.87|0.76
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]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.78||||3.78|0|2.87|0.76
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]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.78||||3.78|2.61|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.78||||3.78|0.76|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.78||||3.78|2.61|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.78||||3.78|1.47|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.78||||3.78||2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.78||||3.78||2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.78||||3.78||2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.78||||3.78|2.61|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.78||||3.78|0|2.87|0.76
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]|3.78||||3.78|0|2.87|0.76
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.78||||3.78||2.87|0.76
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.66||||7.66||5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.66||||7.66|3.83|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.66||||7.66|2.98|5.82|1.53
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]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.66||||7.66|5.52|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.66||||7.66|3.83|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.66||||7.66|3.83|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.66||||7.66|5.82|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.66||||7.66|5.29|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.66||||7.66|3.06|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.66||||7.66||5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.66||||7.66|5.29|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.66||||7.66|3.83|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.66||||7.66|5.29|5.82|1.53
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]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.66||||7.66|0|5.82|1.53
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]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.66||||7.66|5.29|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|7.66||||7.66|1.53|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.66||||7.66|5.29|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.66||||7.66|2.98|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.66||||7.66||5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.66||||7.66||5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.66||||7.66||5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.66||||7.66|5.29|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.66||||7.66|0|5.82|1.53
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]|7.66||||7.66|0|5.82|1.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.66||||7.66||5.82|1.53
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.51||||8.51||6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.51||||8.51|4.26|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.51||||8.51|6.13|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.51||||8.51|4.26|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.51||||8.51|4.26|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.51||||8.51|6.47|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.51||||8.51|3.4|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.51||||8.51||6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.51||||8.51|4.26|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|Self-pay|Self-pay|8.51||||8.51|1.7|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.51||||8.51|3.31|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.51||||8.51||6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.51||||8.51||6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.51||||8.51||6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.51||||8.51|5.87|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.51||||8.51|0|6.47|1.7
437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.51||||8.51||6.47|1.7
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AARP [1000]|AARP [100000]|362.74||||362.74||275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|362.74||||362.74|181.37|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|362.74||||362.74|261.17|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|362.74||||362.74|181.37|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|362.74||||362.74|181.37|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|362.74||||362.74|275.68|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|362.74||||362.74|145.1|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|362.74||||362.74||275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|362.74||||362.74|181.37|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|Self-pay|Self-pay|362.74||||362.74|72.55|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|TML [1980]|TML [198000]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|362.74||||362.74|141.18|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|362.74||||362.74||275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|362.74||||362.74||275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|362.74||||362.74||275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|362.74||||362.74|250.29|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|362.74||||362.74|0|275.68|72.55
43717|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|362.74||||362.74||275.68|72.55
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AARP [1000]|AARP [100000]|439.76||||439.76|192|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA [1015]|AETNA [101529]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMBETTER [2930]|AMBETTER [293000]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|439.76||||439.76|219.88|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|439.76||||439.76|316.63|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|439.76||||439.76|219.88|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|439.76||||439.76|219.88|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|439.76||||439.76|334.22|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA [1260]|CIGNA PPO [126025]|439.76||||439.76|175.9|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|439.76||||439.76|192|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|439.76||||439.76|219.88|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|Self-pay|Self-pay|439.76||||439.76|87.95|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|TML [1980]|TML [198000]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|439.76||||439.76|171.15|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|439.76||||439.76|192|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNICARE [2040]|UNICARE [204000]|439.76||||439.76|192|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|439.76||||439.76|192|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WEB TPA [2115]|WEB TPA [211500]|439.76||||439.76|303.43|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|439.76||||439.76|0|334.22|87.95
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]|439.76||||439.76|0|334.22|87.95
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WORKER'S COMP [2125]|TML WC [212537]|439.76||||439.76|192|334.22|87.95
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AARP [1000]|AARP [100000]|343.03||||343.03|192|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA [1015]|AETNA [101529]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMBETTER [2930]|AMBETTER [293000]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|343.03||||343.03|171.52|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.03||||343.03|246.98|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.03||||343.03|171.52|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.03||||343.03|171.52|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|343.03||||343.03|260.7|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA [1260]|CIGNA PPO [126025]|343.03||||343.03|137.21|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|343.03||||343.03|192|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|343.03||||343.03|171.52|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|Self-pay|Self-pay|343.03||||343.03|68.61|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|TML [1980]|TML [198000]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.03||||343.03|133.51|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.03||||343.03|192|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNICARE [2040]|UNICARE [204000]|343.03||||343.03|192|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.03||||343.03|192|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WEB TPA [2115]|WEB TPA [211500]|343.03||||343.03|236.69|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.03||||343.03|0|260.7|68.61
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WORKER'S COMP [2125]|TML WC [212537]|343.03||||343.03|192|260.7|68.61
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AARP [1000]|AARP [100000]|69||||69|69|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AETNA [1015]|AETNA [101529]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|34.5|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|49.68|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|34.5|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|52.44|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|69|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|34.5|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|Self-pay|Self-pay|69||||69|13.8|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|TML [1980]|TML [198000]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|26.85|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|69|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|69||||69|69|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|69|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69|0|69|13.8
44097129|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|69|69|13.8
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AARP [1000]|AARP [100000]|66||||66|66|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AETNA [1015]|AETNA [101529]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|66|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|Self-pay|Self-pay|66||||66|13.2|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|TML [1980]|TML [198000]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|66|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNICARE [2040]|UNICARE [204000]|66||||66|66|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|66|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66|0|66|13.2
44097130|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES|1|WORKER'S COMP [2125]|TML WC [212537]|66||||66|66|66|13.2
4410001|EAP||HH SLP ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|109.33|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|75.93|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|115.41|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|Self-pay|Self-pay|||||151.85|30.37|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|TML [1980]|TML [198000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85|0|115.41|30.37
4410001|EAP||HH SLP ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|109.33|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|75.93|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|115.41|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|Self-pay|Self-pay|||||151.85|30.37|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|TML [1980]|TML [198000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85|0|115.41|30.37
4410002|EAP||HH SLP INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AARP [1000]|AARP [100000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMBETTER [2930]|AMBETTER [293000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|109.33|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|75.93|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||151.85|115.41|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA [1260]|CIGNA PPO [126025]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|Self-pay|Self-pay|||||151.85|30.37|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|TML [1980]|TML [198000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UNICARE [2040]|UNICARE [204000]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WEB TPA [2115]|WEB TPA [211500]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85|0|115.41|30.37
4410003|EAP||HH SLP MAINTENANCE|1|WORKER'S COMP [2125]|TML WC [212537]|||||151.85|0|115.41|30.37
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.8||||5.8||4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.8||||5.8|2.9|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.8||||5.8|2.26|4.41|1.16
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]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.8||||5.8|4.18|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.8||||5.8|2.9|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.8||||5.8|2.9|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.8||||5.8|4.41|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.8||||5.8|4|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.8||||5.8|2.32|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.8||||5.8||4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.8||||5.8|4|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.8||||5.8|2.9|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.8||||5.8|4|4.41|1.16
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]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.8||||5.8|0|4.41|1.16
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]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.8||||5.8|4|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|Self-pay|Self-pay|5.8||||5.8|1.16|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|TML [1980]|TML [198000]|5.8||||5.8|4|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.8||||5.8|2.26|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.8||||5.8||4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.8||||5.8||4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.8||||5.8||4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.8||||5.8|4|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.8||||5.8|0|4.41|1.16
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]|5.8||||5.8|0|4.41|1.16
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.8||||5.8||4.41|1.16
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.98||||17.98||13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.98||||17.98|8.99|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.98||||17.98|7|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.98||||17.98|12.95|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.98||||17.98|8.99|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.98||||17.98|8.99|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.98||||17.98|13.66|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.98||||17.98|12.41|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.98||||17.98|7.19|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.98||||17.98||13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.98||||17.98|12.41|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.98||||17.98|8.99|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.98||||17.98|12.41|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.98||||17.98|12.41|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|Self-pay|Self-pay|17.98||||17.98|3.6|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|TML [1980]|TML [198000]|17.98||||17.98|12.41|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.98||||17.98|7|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.98||||17.98||13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.98||||17.98||13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.98||||17.98||13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.98||||17.98|12.41|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.98||||17.98|8.99|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.98||||17.98|7|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.98||||17.98|12.95|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.98||||17.98|8.99|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.98||||17.98|8.99|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.98||||17.98|13.66|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.98||||17.98|12.41|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.98||||17.98|7.19|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.98||||17.98|12.41|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.98||||17.98|8.99|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.98||||17.98|12.41|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.98||||17.98|12.41|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|Self-pay|Self-pay|17.98||||17.98|3.6|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|TML [1980]|TML [198000]|17.98||||17.98|12.41|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.98||||17.98|7|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.98||||17.98||13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.98||||17.98|12.41|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.98||||17.98|8.99|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.98||||17.98|7|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.98||||17.98|12.95|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.98||||17.98|8.99|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.98||||17.98|8.99|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.98||||17.98|13.66|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.98||||17.98|12.41|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.98||||17.98|7.19|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.98||||17.98|12.41|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.98||||17.98|8.99|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.98||||17.98|12.41|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.98||||17.98|12.41|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|Self-pay|Self-pay|17.98||||17.98|3.6|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|TML [1980]|TML [198000]|17.98||||17.98|12.41|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.98||||17.98|7|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.98||||17.98||13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.98||||17.98|12.41|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.98||||17.98|8.99|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.98||||17.98|7|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.98||||17.98|12.95|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.98||||17.98|8.99|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.98||||17.98|8.99|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.98||||17.98|13.66|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.98||||17.98|12.41|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|17.98||||17.98|7.19|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.98||||17.98|12.41|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.98||||17.98|8.99|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.98||||17.98|12.41|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.98||||17.98|12.41|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|Self-pay|Self-pay|17.98||||17.98|3.6|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|TML [1980]|TML [198000]|17.98||||17.98|12.41|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.98||||17.98|7|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.98||||17.98||13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|17.98||||17.98|12.41|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.98||||17.98|0|13.66|3.6
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]|17.98||||17.98|0|13.66|3.6
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|17.98||||17.98||13.66|3.6
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AARP [1000]|AARP [100000]|594.97||||594.97|192|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA [1015]|AETNA [101529]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMBETTER [2930]|AMBETTER [293000]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|594.97||||594.97|297.49|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|594.97||||594.97|231.56|452.18|118.99
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]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594.97||||594.97|428.38|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594.97||||594.97|297.49|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594.97||||594.97|297.49|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|594.97||||594.97|452.18|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|594.97||||594.97|410.53|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA [1260]|CIGNA PPO [126025]|594.97||||594.97|237.99|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|594.97||||594.97|192|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594.97||||594.97|410.53|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|594.97||||594.97|297.49|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|594.97||||594.97|410.53|452.18|118.99
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]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594.97||||594.97|0|452.18|118.99
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]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594.97||||594.97|410.53|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|Self-pay|Self-pay|594.97||||594.97|118.99|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|TML [1980]|TML [198000]|594.97||||594.97|410.53|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594.97||||594.97|231.56|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594.97||||594.97|192|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNICARE [2040]|UNICARE [204000]|594.97||||594.97|192|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594.97||||594.97|192|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WEB TPA [2115]|WEB TPA [211500]|594.97||||594.97|410.53|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594.97||||594.97|0|452.18|118.99
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]|594.97||||594.97|0|452.18|118.99
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WORKER'S COMP [2125]|TML WC [212537]|594.97||||594.97|192|452.18|118.99
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AARP [1000]|AARP [100000]|92.4||||92.4||70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|66.53|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|46.2|70.22|18.48
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]|92.4||||92.4|46.2|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4||70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|Self-pay|Self-pay|92.4||||92.4|18.48|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4||70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4||70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4||70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4||70.22|18.48
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AARP [1000]|AARP [100000]|562.5||||562.5|192|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA [1015]|AETNA [101529]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMBETTER [2930]|AMBETTER [293000]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|562.5||||562.5|281.25|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|562.5||||562.5|405|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|562.5||||562.5|281.25|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|562.5||||562.5|281.25|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|562.5||||562.5|427.5|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA [1260]|CIGNA PPO [126025]|562.5||||562.5|225|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|562.5||||562.5|192|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|562.5||||562.5|281.25|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|Self-pay|Self-pay|562.5||||562.5|112.5|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|TML [1980]|TML [198000]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|562.5||||562.5|218.93|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|562.5||||562.5|192|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNICARE [2040]|UNICARE [204000]|562.5||||562.5|192|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|562.5||||562.5|192|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WEB TPA [2115]|WEB TPA [211500]|562.5||||562.5|388.13|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|562.5||||562.5|0|427.5|112.5
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]|562.5||||562.5|0|427.5|112.5
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WORKER'S COMP [2125]|TML WC [212537]|562.5||||562.5|192|427.5|112.5
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AARP [1000]|AARP [100000]|554.48||||554.48|192|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA [1015]|AETNA [101529]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMBETTER [2930]|AMBETTER [293000]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|554.48||||554.48|277.24|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|554.48||||554.48|399.23|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|554.48||||554.48|277.24|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|554.48||||554.48|277.24|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|554.48||||554.48|421.4|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA [1260]|CIGNA PPO [126025]|554.48||||554.48|221.79|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|554.48||||554.48|192|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|554.48||||554.48|277.24|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|Self-pay|Self-pay|554.48||||554.48|110.9|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|TML [1980]|TML [198000]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|554.48||||554.48|215.8|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|554.48||||554.48|192|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNICARE [2040]|UNICARE [204000]|554.48||||554.48|192|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|554.48||||554.48|192|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WEB TPA [2115]|WEB TPA [211500]|554.48||||554.48|382.59|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|554.48||||554.48|0|421.4|110.9
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]|554.48||||554.48|0|421.4|110.9
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WORKER'S COMP [2125]|TML WC [212537]|554.48||||554.48|192|421.4|110.9
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AARP [1000]|AARP [100000]|1115.7||||1115.7|192|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA [1015]|AETNA [101529]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMBETTER [2930]|AMBETTER [293000]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1115.7||||1115.7|557.85|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1115.7||||1115.7|803.3|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1115.7||||1115.7|557.85|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1115.7||||1115.7|557.85|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1115.7||||1115.7|847.93|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA [1260]|CIGNA PPO [126025]|1115.7||||1115.7|446.28|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1115.7||||1115.7|192|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1115.7||||1115.7|557.85|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|Self-pay|Self-pay|1115.7||||1115.7|223.14|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|TML [1980]|TML [198000]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1115.7||||1115.7|434.23|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1115.7||||1115.7|192|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNICARE [2040]|UNICARE [204000]|1115.7||||1115.7|192|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1115.7||||1115.7|192|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WEB TPA [2115]|WEB TPA [211500]|1115.7||||1115.7|769.83|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1115.7||||1115.7|0|847.93|192
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]|1115.7||||1115.7|0|847.93|192
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WORKER'S COMP [2125]|TML WC [212537]|1115.7||||1115.7|192|847.93|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AARP [1000]|AARP [100000]|2380||||2380|192|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA [1015]|AETNA [101529]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMBETTER [2930]|AMBETTER [293000]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2380||||2380|1190|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2380||||2380|1713.6|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2380||||2380|1190|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2380||||2380|1190|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2380||||2380|1808.8|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA [1260]|CIGNA PPO [126025]|2380||||2380|952|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2380||||2380|192|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2380||||2380|1190|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|Self-pay|Self-pay|2380||||2380|476|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|TML [1980]|TML [198000]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2380||||2380|926.3|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2380||||2380|192|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNICARE [2040]|UNICARE [204000]|2380||||2380|192|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2380||||2380|192|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WEB TPA [2115]|WEB TPA [211500]|2380||||2380|1642.2|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2380||||2380|0|1808.8|192
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]|2380||||2380|0|1808.8|192
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WORKER'S COMP [2125]|TML WC [212537]|2380||||2380|192|1808.8|192
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AARP [1000]|AARP [100000]|747.92||||747.92|192|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AETNA [1015]|AETNA [101529]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMBETTER [2930]|AMBETTER [293000]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747.92||||747.92|291.09|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|747.92||||747.92|373.96|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|747.92||||747.92|291.09|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
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]|747.92||||747.92|538.5|568.42|149.58
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]|747.92||||747.92|373.96|568.42|149.58
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]|747.92||||747.92|373.96|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|747.92||||747.92|568.42|568.42|149.58
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]|747.92||||747.92|291.09|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|747.92||||747.92|516.06|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA [1260]|CIGNA PPO [126025]|747.92||||747.92|299.17|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|747.92||||747.92|192|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747.92||||747.92|516.06|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|747.92||||747.92|373.96|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|747.92||||747.92|516.06|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747.92||||747.92|0|568.42|149.58
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]|747.92||||747.92|291.09|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747.92||||747.92|0|568.42|149.58
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]|747.92||||747.92|291.09|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747.92||||747.92|516.06|568.42|149.58
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]|747.92||||747.92|291.09|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|Self-pay|Self-pay|747.92||||747.92|149.58|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|TML [1980]|TML [198000]|747.92||||747.92|516.06|568.42|149.58
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]|747.92||||747.92|291.09|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747.92||||747.92|192|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNICARE [2040]|UNICARE [204000]|747.92||||747.92|192|568.42|149.58
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]|747.92||||747.92|192|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WEB TPA [2115]|WEB TPA [211500]|747.92||||747.92|516.06|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
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]|747.92||||747.92|0|568.42|149.58
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WORKER'S COMP [2125]|TML WC [212537]|747.92||||747.92|192|568.42|149.58
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AARP [1000]|AARP [100000]|826.65||||826.65|192|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA [1015]|AETNA [101529]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMBETTER [2930]|AMBETTER [293000]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|826.65||||826.65|413.33|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|826.65||||826.65|595.19|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|826.65||||826.65|413.33|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|826.65||||826.65|413.33|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|826.65||||826.65|628.25|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA [1260]|CIGNA PPO [126025]|826.65||||826.65|330.66|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|826.65||||826.65|192|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|826.65||||826.65|413.33|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|Self-pay|Self-pay|826.65||||826.65|165.33|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|TML [1980]|TML [198000]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|826.65||||826.65|321.73|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|826.65||||826.65|192|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNICARE [2040]|UNICARE [204000]|826.65||||826.65|192|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|826.65||||826.65|192|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WEB TPA [2115]|WEB TPA [211500]|826.65||||826.65|570.39|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|826.65||||826.65|0|628.25|165.33
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WORKER'S COMP [2125]|TML WC [212537]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AARP [1000]|AARP [100000]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA [1015]|AETNA [101529]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMBETTER [2930]|AMBETTER [293000]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|826.65||||826.65|413.33|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|826.65||||826.65|595.19|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|826.65||||826.65|413.33|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|826.65||||826.65|413.33|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|826.65||||826.65|628.25|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA [1260]|CIGNA PPO [126025]|826.65||||826.65|330.66|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|826.65||||826.65|413.33|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|Self-pay|Self-pay|826.65||||826.65|165.33|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|TML [1980]|TML [198000]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|826.65||||826.65|321.73|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNICARE [2040]|UNICARE [204000]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|826.65||||826.65|192|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WEB TPA [2115]|WEB TPA [211500]|826.65||||826.65|570.39|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|826.65||||826.65|0|628.25|165.33
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]|826.65||||826.65|0|628.25|165.33
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WORKER'S COMP [2125]|TML WC [212537]|826.65||||826.65|192|628.25|165.33
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AARP [1000]|AARP [100000]|1127.5||||1127.5|192|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AETNA [1015]|AETNA [101529]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AMBETTER [2930]|AMBETTER [293000]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1127.5||||1127.5|563.75|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1127.5||||1127.5|811.8|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1127.5||||1127.5|563.75|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1127.5||||1127.5|563.75|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1127.5||||1127.5|856.9|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|CIGNA [1260]|CIGNA PPO [126025]|1127.5||||1127.5|451|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1127.5||||1127.5|192|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1127.5||||1127.5|563.75|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|Self-pay|Self-pay|1127.5||||1127.5|225.5|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|TML [1980]|TML [198000]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1127.5||||1127.5|438.82|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1127.5||||1127.5|192|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|UNICARE [2040]|UNICARE [204000]|1127.5||||1127.5|192|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1127.5||||1127.5|192|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|WEB TPA [2115]|WEB TPA [211500]|1127.5||||1127.5|777.98|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1127.5||||1127.5|0|856.9|192
44492700|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC UNLISTED OTORHINOLARYNGOLOGICAL SERVICE|1|WORKER'S COMP [2125]|TML WC [212537]|1127.5||||1127.5|192|856.9|192
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AARP [1000]|AARP [100000]|528||||528||401.28|105.6
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]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|528||||528|0|401.28|105.6
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]|528||||528|205.5|401.28|105.6
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]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|528||||528|264|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|528||||528|205.5|401.28|105.6
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]|528||||528|0|401.28|105.6
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]|528||||528|380.16|401.28|105.6
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]|528||||528|264|401.28|105.6
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]|528||||528|264|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|528||||528|401.28|401.28|105.6
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]|528||||528|205.5|401.28|105.6
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]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|528||||528|364.32|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|528||||528|211.2|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|528||||528||401.28|105.6
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]|528||||528|364.32|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|528||||528|264|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|528||||528|364.32|401.28|105.6
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]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|0|401.28|105.6
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]|528||||528|205.5|401.28|105.6
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]|528||||528|0|401.28|105.6
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]|528||||528|0|401.28|105.6
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]|528||||528|205.5|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|364.32|401.28|105.6
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]|528||||528|205.5|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|Self-pay|Self-pay|528||||528|105.6|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|TML [1980]|TML [198000]|528||||528|364.32|401.28|105.6
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]|528||||528|205.5|401.28|105.6
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]|528||||528||401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|528||||528||401.28|105.6
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]|528||||528||401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|528||||528|364.32|401.28|105.6
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]|528||||528|0|401.28|105.6
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]|528||||528|0|401.28|105.6
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|528||||528||401.28|105.6
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|18.75||||18.75||14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.75||||18.75|9.38|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.75||||18.75|7.3|14.25|3.75
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]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.75||||18.75|13.5|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.75||||18.75|9.38|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.75||||18.75|9.38|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.75||||18.75|14.25|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.75||||18.75|12.94|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|18.75||||18.75|7.5|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.75||||18.75||14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.75||||18.75|12.94|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.75||||18.75|9.38|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.75||||18.75|12.94|14.25|3.75
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]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.75||||18.75|0|14.25|3.75
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]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.75||||18.75|12.94|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|18.75||||18.75|3.75|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|TML [1980]|TML [198000]|18.75||||18.75|12.94|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.75||||18.75|7.3|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.75||||18.75||14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|18.75||||18.75||14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.75||||18.75||14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|18.75||||18.75|12.94|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.75||||18.75|0|14.25|3.75
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]|18.75||||18.75|0|14.25|3.75
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|18.75||||18.75||14.25|3.75
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|27.72||||27.72||21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.72||||27.72|13.86|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.72||||27.72|10.79|21.07|5.54
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]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.72||||27.72|19.96|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.72||||27.72|13.86|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.72||||27.72|13.86|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.72||||27.72|21.07|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.72||||27.72|19.13|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|27.72||||27.72|11.09|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.72||||27.72||21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.72||||27.72|19.13|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.72||||27.72|13.86|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.72||||27.72|19.13|21.07|5.54
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]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.72||||27.72|0|21.07|5.54
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]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.72||||27.72|19.13|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|27.72||||27.72|5.54|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|TML [1980]|TML [198000]|27.72||||27.72|19.13|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.72||||27.72|10.79|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.72||||27.72||21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|27.72||||27.72||21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.72||||27.72||21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|27.72||||27.72|19.13|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.72||||27.72|0|21.07|5.54
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]|27.72||||27.72|0|21.07|5.54
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|27.72||||27.72||21.07|5.54
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|75.9||||75.9||57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMBETTER [2930]|AMBETTER [293000]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|75.9||||75.9|37.95|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|75.9||||75.9|29.54|57.68|15.18
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]|75.9||||75.9|0|57.68|15.18
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]|75.9||||75.9|54.65|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.9||||75.9|37.95|57.68|15.18
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]|75.9||||75.9|37.95|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|75.9||||75.9|57.68|57.68|15.18
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]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|75.9||||75.9|52.37|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|75.9||||75.9|30.36|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|75.9||||75.9||57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|75.9||||75.9|52.37|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|75.9||||75.9|37.95|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|75.9||||75.9|52.37|57.68|15.18
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]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.9||||75.9|0|57.68|15.18
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]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|75.9||||75.9|52.37|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|75.9||||75.9|15.18|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|TML [1980]|TML [198000]|75.9||||75.9|52.37|57.68|15.18
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]|75.9||||75.9|29.54|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.9||||75.9||57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNICARE [2040]|UNICARE [204000]|75.9||||75.9||57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.9||||75.9||57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WEB TPA [2115]|WEB TPA [211500]|75.9||||75.9|52.37|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.9||||75.9|0|57.68|15.18
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]|75.9||||75.9|0|57.68|15.18
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|75.9||||75.9||57.68|15.18
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.58||||1.58||1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.58||||1.58|0.79|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.58||||1.58|0.61|1.2|0.32
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]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.58||||1.58|1.14|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.58||||1.58|0.79|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.58||||1.58|0.79|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.58||||1.58|1.2|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.58||||1.58|1.09|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.58||||1.58|0.63|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.58||||1.58||1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.58||||1.58|1.09|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.58||||1.58|0.79|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.58||||1.58|1.09|1.2|0.32
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]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.58||||1.58|0|1.2|0.32
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]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.58||||1.58|1.09|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.58||||1.58|0.32|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.58||||1.58|1.09|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.58||||1.58|0.61|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.58||||1.58||1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.58||||1.58||1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.58||||1.58||1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.58||||1.58|1.09|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.58||||1.58|0|1.2|0.32
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]|1.58||||1.58|0|1.2|0.32
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.58||||1.58||1.2|0.32
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.35||||2.35||1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.35||||2.35|1.18|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.35||||2.35|0.91|1.79|0.47
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]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.35||||2.35|1.69|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.35||||2.35|1.18|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.35||||2.35|1.18|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.35||||2.35|1.79|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.35||||2.35|1.62|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.35||||2.35|0.94|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.35||||2.35||1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.35||||2.35|1.62|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.35||||2.35|1.18|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.35||||2.35|1.62|1.79|0.47
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]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.35||||2.35|0|1.79|0.47
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]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.35||||2.35|1.62|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.35||||2.35|0.47|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.35||||2.35|1.62|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.35||||2.35|0.91|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.35||||2.35||1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.35||||2.35||1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.35||||2.35||1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.35||||2.35|1.62|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.35||||2.35|0|1.79|0.47
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]|2.35||||2.35|0|1.79|0.47
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.35||||2.35||1.79|0.47
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.98||||1.98||1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.98||||1.98|0.99|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.98||||1.98|0.77|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
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]|1.98||||1.98|1.43|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.98||||1.98|0.99|1.5|0.4
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]|1.98||||1.98|0.99|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.98||||1.98|1.5|1.5|0.4
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]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.98||||1.98|1.37|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.98||||1.98|0.79|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.98||||1.98||1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.98||||1.98|1.37|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.98||||1.98|0.99|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.98||||1.98|1.37|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.98||||1.98|0|1.5|0.4
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]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.98||||1.98|1.37|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.98||||1.98|0.4|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.98||||1.98|1.37|1.5|0.4
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]|1.98||||1.98|0.77|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.98||||1.98||1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.98||||1.98||1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.98||||1.98||1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.98||||1.98|1.37|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.98||||1.98|0|1.5|0.4
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]|1.98||||1.98|0|1.5|0.4
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.98||||1.98||1.5|0.4
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.85||||4.85||3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.85||||4.85|2.43|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.85||||4.85|1.89|3.69|0.97
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]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.85||||4.85|3.49|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.85||||4.85|2.43|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.85||||4.85|2.43|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.85||||4.85|3.69|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.85||||4.85|3.35|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|4.85||||4.85|1.94|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.85||||4.85||3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.85||||4.85|3.35|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.85||||4.85|2.43|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.85||||4.85|3.35|3.69|0.97
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]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.85||||4.85|0|3.69|0.97
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]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.85||||4.85|3.35|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.85||||4.85|0.97|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|4.85||||4.85|3.35|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.85||||4.85|1.89|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.85||||4.85||3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|4.85||||4.85||3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.85||||4.85||3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|4.85||||4.85|3.35|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.85||||4.85|0|3.69|0.97
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]|4.85||||4.85|0|3.69|0.97
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|4.85||||4.85||3.69|0.97
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.64||||2.64||2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|1.03|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|1.9|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.32|2.01|0.53
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]|2.64||||2.64|1.32|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|2.01|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64||2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.64||||2.64|0.53|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.64||||2.64|1.82|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64||2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.64||||2.64||2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64||2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64||2.01|0.53
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.66||||0.66||0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.66||||0.66|0.33|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.66||||0.66|0.26|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.48|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.33|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.33|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.66||||0.66|0.5|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.66||||0.66|0.46|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.66||||0.66||0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.66||||0.66|0.33|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.66||||0.66|0.46|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0|0.5|0.13
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]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.66||||0.66|0.13|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.66||||0.66|0.46|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.26|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66||0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.66||||0.66||0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66||0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.66||||0.66|0.46|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66|0|0.5|0.13
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]|0.66||||0.66|0|0.5|0.13
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.66||||0.66||0.5|0.13
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AARP [1000]|AARP [100000]|766||||766|258|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AETNA [1015]|AETNA [101529]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AMBETTER [2930]|AMBETTER [293000]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|766||||766|343.79|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|766||||766|551.52|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|766||||766|383|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|766||||766|383|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|766||||766|582.16|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|CIGNA [1260]|CIGNA PPO [126025]|766||||766|306.4|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|766||||766|258|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|766||||766|343.79|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|Self-pay|Self-pay|766||||766|153.2|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|TML [1980]|TML [198000]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|766||||766|298.13|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|766||||766|258|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|UNICARE [2040]|UNICARE [204000]|766||||766|258|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|766||||766|258|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|WEB TPA [2115]|WEB TPA [211500]|766||||766|528.54|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|766||||766|0|582.16|153.2
46094681|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CO2/O2 GAS ANALYSIS|1|WORKER'S COMP [2125]|TML WC [212537]|766||||766|258|582.16|153.2
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AARP [1000]|AARP [100000]|345.75||||345.75|258|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA [1015]|AETNA [101529]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMBETTER [2930]|AMBETTER [293000]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|345.75||||345.75|172.88|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345.75||||345.75|248.94|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345.75||||345.75|172.88|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345.75||||345.75|172.88|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|345.75||||345.75|262.77|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA [1260]|CIGNA PPO [126025]|345.75||||345.75|138.3|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|345.75||||345.75|258|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|345.75||||345.75|172.88|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|Self-pay|Self-pay|345.75||||345.75|69.15|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|TML [1980]|TML [198000]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345.75||||345.75|134.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345.75||||345.75|258|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNICARE [2040]|UNICARE [204000]|345.75||||345.75|258|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345.75||||345.75|258|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WEB TPA [2115]|WEB TPA [211500]|345.75||||345.75|238.57|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345.75||||345.75|0|262.77|69.15
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WORKER'S COMP [2125]|TML WC [212537]|345.75||||345.75|258|262.77|69.15
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AARP [1000]|AARP [100000]|51.75||||51.75|51.75|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA [1015]|AETNA [101529]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMBETTER [2930]|AMBETTER [293000]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|51.75||||51.75|25.88|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.75||||51.75|37.26|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.75||||51.75|25.88|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.75||||51.75|25.88|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|51.75||||51.75|39.33|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA [1260]|CIGNA PPO [126025]|51.75||||51.75|20.7|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|51.75||||51.75|51.75|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|51.75||||51.75|25.88|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|Self-pay|Self-pay|51.75||||51.75|10.35|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|TML [1980]|TML [198000]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.75||||51.75|20.14|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.75||||51.75|51.75|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNICARE [2040]|UNICARE [204000]|51.75||||51.75|51.75|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.75||||51.75|51.75|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WEB TPA [2115]|WEB TPA [211500]|51.75||||51.75|35.71|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.75||||51.75|0|51.75|10.35
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WORKER'S COMP [2125]|TML WC [212537]|51.75||||51.75|51.75|51.75|10.35
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AARP [1000]|AARP [100000]|1284.75||||1284.75|258|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA [1015]|AETNA [101529]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMBETTER [2930]|AMBETTER [293000]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1284.75||||1284.75|181.42|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1284.75||||1284.75|925.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1284.75||||1284.75|642.38|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1284.75||||1284.75|642.38|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1284.75||||1284.75|976.41|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA [1260]|CIGNA PPO [126025]|1284.75||||1284.75|513.9|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1284.75||||1284.75|258|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1284.75||||1284.75|181.42|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|Self-pay|Self-pay|1284.75||||1284.75|256.95|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|TML [1980]|TML [198000]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1284.75||||1284.75|500.02|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1284.75||||1284.75|258|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNICARE [2040]|UNICARE [204000]|1284.75||||1284.75|258|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1284.75||||1284.75|258|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WEB TPA [2115]|WEB TPA [211500]|1284.75||||1284.75|886.48|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1284.75||||1284.75|0|976.41|181.42
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WORKER'S COMP [2125]|TML WC [212537]|1284.75||||1284.75|258|976.41|181.42
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AARP [1000]|AARP [100000]|404||||404|258|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA [1015]|AETNA [101529]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMBETTER [2930]|AMBETTER [293000]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|404||||404|181.42|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|404||||404|290.88|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|404||||404|202|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|404||||404|202|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|404||||404|307.04|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA [1260]|CIGNA PPO [126025]|404||||404|161.6|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|404||||404|258|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|404||||404|181.42|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|Self-pay|Self-pay|404||||404|80.8|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|TML [1980]|TML [198000]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|404||||404|157.24|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|404||||404|258|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNICARE [2040]|UNICARE [204000]|404||||404|258|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|404||||404|258|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WEB TPA [2115]|WEB TPA [211500]|404||||404|278.76|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|404||||404|0|307.04|80.8
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WORKER'S COMP [2125]|TML WC [212537]|404||||404|258|307.04|80.8
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AARP [1000]|AARP [100000]|576.84||||576.84|288.42|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AETNA [1015]|AETNA [101529]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMBETTER [2930]|AMBETTER [293000]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|576.84||||576.84|224.51|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|576.84||||576.84|50.58|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|576.84||||576.84|224.51|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
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]|576.84||||576.84|415.32|438.4|50.58
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]|576.84||||576.84|288.42|438.4|50.58
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]|576.84||||576.84|288.42|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|576.84||||576.84|438.4|438.4|50.58
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]|576.84||||576.84|224.51|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|576.84||||576.84|398.02|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|576.84||||576.84|230.74|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|576.84||||576.84|288.42|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|576.84||||576.84|398.02|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|576.84||||576.84|50.58|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|576.84||||576.84|398.02|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|576.84||||576.84|0|438.4|50.58
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]|576.84||||576.84|224.51|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|576.84||||576.84|0|438.4|50.58
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]|576.84||||576.84|224.51|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|576.84||||576.84|398.02|438.4|50.58
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]|576.84||||576.84|224.51|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|Self-pay|Self-pay|576.84||||576.84|115.37|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|TML [1980]|TML [198000]|576.84||||576.84|398.02|438.4|50.58
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]|576.84||||576.84|224.51|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|576.84||||576.84|288.42|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNICARE [2040]|UNICARE [204000]|576.84||||576.84|288.42|438.4|50.58
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]|576.84||||576.84|288.42|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WEB TPA [2115]|WEB TPA [211500]|576.84||||576.84|398.02|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
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]|576.84||||576.84|0|438.4|50.58
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|576.84||||576.84|288.42|438.4|50.58
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|79.2||||79.2|39.6|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.2||||79.2|30.82|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|79.2||||79.2|1.16|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|79.2||||79.2|30.82|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
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]|79.2||||79.2|57.02|60.19|1.16
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]|79.2||||79.2|39.6|60.19|1.16
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]|79.2||||79.2|39.6|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|79.2||||79.2|60.19|60.19|1.16
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]|79.2||||79.2|30.82|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|79.2||||79.2|54.65|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|79.2||||79.2|31.68|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|79.2||||79.2|39.6|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|79.2||||79.2|54.65|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|79.2||||79.2|1.16|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|79.2||||79.2|54.65|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.2||||79.2|0|60.19|1.16
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]|79.2||||79.2|30.82|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.2||||79.2|0|60.19|1.16
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]|79.2||||79.2|30.82|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|79.2||||79.2|54.65|60.19|1.16
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]|79.2||||79.2|30.82|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|79.2||||79.2|15.84|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TML [1980]|TML [198000]|79.2||||79.2|54.65|60.19|1.16
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]|79.2||||79.2|30.82|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.2||||79.2|39.6|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|79.2||||79.2|39.6|60.19|1.16
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]|79.2||||79.2|39.6|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|79.2||||79.2|54.65|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
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]|79.2||||79.2|0|60.19|1.16
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|79.2||||79.2|39.6|60.19|1.16
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AARP [1000]|AARP [100000]|15.63||||15.63||11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AETNA [1015]|AETNA [101529]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMBETTER [2930]|AMBETTER [293000]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.63||||15.63|7.82|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.63||||15.63|11.25|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.63||||15.63|7.82|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.63||||15.63|7.82|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.63||||15.63|11.88|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|CIGNA [1260]|CIGNA PPO [126025]|15.63||||15.63|6.25|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.63||||15.63||11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.63||||15.63|7.82|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|Self-pay|Self-pay|15.63||||15.63|3.13|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|TML [1980]|TML [198000]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.63||||15.63|6.08|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.63||||15.63||11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UNICARE [2040]|UNICARE [204000]|15.63||||15.63||11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.63||||15.63||11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WEB TPA [2115]|WEB TPA [211500]|15.63||||15.63|10.78|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.63||||15.63|0|11.88|3.13
4712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM CITRATE ORAL SOLUTION|296 mL|WORKER'S COMP [2125]|TML WC [212537]|15.63||||15.63||11.88|3.13
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|145.2||||145.2|72.6|110.35|1.16
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]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|56.51|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|1.16|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|56.51|110.35|1.16
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]|145.2||||145.2|0|110.35|1.16
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]|145.2||||145.2|104.54|110.35|1.16
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]|145.2||||145.2|72.6|110.35|1.16
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]|145.2||||145.2|72.6|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|110.35|110.35|1.16
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]|145.2||||145.2|56.51|110.35|1.16
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]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2|72.6|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|1.16|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|110.35|1.16
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]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|56.51|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|0|110.35|1.16
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]|145.2||||145.2|56.51|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|56.51|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|145.2||||145.2|29.04|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|145.2||||145.2|100.19|110.35|1.16
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]|145.2||||145.2|56.51|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2|72.6|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|145.2||||145.2|72.6|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2|72.6|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2|0|110.35|1.16
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]|145.2||||145.2|0|110.35|1.16
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2|72.6|110.35|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AARP [1000]|AARP [100000]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AETNA [1015]|AETNA [101529]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AMBETTER [2930]|AMBETTER [293000]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.42||||24.42|1.16|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.42||||24.42|17.58|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.42||||24.42|18.56|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|CIGNA [1260]|CIGNA PPO [126025]|24.42||||24.42|9.77|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|GROUP PENSION ADMIN [1450]|GPA [145000]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.42||||24.42|1.16|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|PHCS [1780]|PHCS MULTIPLAN [178000]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|Self-pay|Self-pay|24.42||||24.42|4.88|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|TML [1980]|TML [198000]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.42||||24.42|9.5|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|UNICARE [2040]|UNICARE [204000]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.42||||24.42|12.21|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|WEB TPA [2115]|WEB TPA [211500]|24.42||||24.42|16.85|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.42||||24.42|0|18.56|1.16
473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 250 MG SOLUTION FOR INJECTION|0.25 g|WORKER'S COMP [2125]|TML WC [212537]|24.42||||24.42|12.21|18.56|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|31.29||||31.29|1.16|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.29||||31.29|22.53|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|31.29||||31.29|23.78|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|31.29||||31.29|12.52|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|31.29||||31.29|1.16|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|31.29||||31.29|6.26|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.29||||31.29|12.18|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.29||||31.29|15.65|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|31.29||||31.29|21.59|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.29||||31.29|0|23.78|1.16
474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|31.29||||31.29|15.65|23.78|1.16
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AARP [1000]|AARP [100000]|5398.73||||5398.73|297|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA [1015]|AETNA [101529]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5398.73||||5398.73|627.76|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5398.73||||5398.73|3887.09|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5398.73||||5398.73|2699.37|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5398.73||||5398.73|2699.37|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5398.73||||5398.73|4103.03|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|5398.73||||5398.73|2159.49|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5398.73||||5398.73|297|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5398.73||||5398.73|627.76|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|Self-pay|Self-pay|5398.73||||5398.73|1079.75|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|TML [1980]|TML [198000]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5398.73||||5398.73|2101.19|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5398.73||||5398.73|297|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNICARE [2040]|UNICARE [204000]|5398.73||||5398.73|297|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5398.73||||5398.73|297|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|5398.73||||5398.73|3725.12|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5398.73||||5398.73|0|4103.03|297
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|5398.73||||5398.73|297|4103.03|297
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AARP [1000]|AARP [100000]|1343.64||||1343.64|297|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA [1015]|AETNA [101529]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMBETTER [2930]|AMBETTER [293000]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1343.64||||1343.64|299.17|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1343.64||||1343.64|967.42|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1343.64||||1343.64|671.82|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1343.64||||1343.64|671.82|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1343.64||||1343.64|1021.17|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA [1260]|CIGNA PPO [126025]|1343.64||||1343.64|537.46|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1343.64||||1343.64|297|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1343.64||||1343.64|299.17|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|Self-pay|Self-pay|1343.64||||1343.64|268.73|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|TML [1980]|TML [198000]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1343.64||||1343.64|147.7|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1343.64||||1343.64|297|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNICARE [2040]|UNICARE [204000]|1343.64||||1343.64|297|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1343.64||||1343.64|297|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WEB TPA [2115]|WEB TPA [211500]|1343.64||||1343.64|927.11|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1343.64||||1343.64|0|1021.17|147.7
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WORKER'S COMP [2125]|TML WC [212537]|1343.64||||1343.64|297|1021.17|147.7
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AARP [1000]|AARP [100000]|4838||||4838|297|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AETNA [1015]|AETNA [101529]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AMBETTER [2930]|AMBETTER [293000]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4838||||4838|627.76|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4838||||4838|3483.36|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4838||||4838|2419|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4838||||4838|2419|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4838||||4838|3676.88|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA [1260]|CIGNA PPO [126025]|4838||||4838|1935.2|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4838||||4838|297|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4838||||4838|627.76|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|Self-pay|Self-pay|4838||||4838|967.6|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|TML [1980]|TML [198000]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4838||||4838|370.3|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4838||||4838|297|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UNICARE [2040]|UNICARE [204000]|4838||||4838|297|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4838||||4838|297|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WEB TPA [2115]|WEB TPA [211500]|4838||||4838|3338.22|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4838||||4838|0|3676.88|297
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WORKER'S COMP [2125]|TML WC [212537]|4838||||4838|297|3676.88|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AARP [1000]|AARP [100000]|2312.25||||2312.25|297|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AETNA [1015]|AETNA [101529]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AMBETTER [2930]|AMBETTER [293000]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2312.25||||2312.25|1156.13|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2312.25||||2312.25|1664.82|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2312.25||||2312.25|1156.13|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2312.25||||2312.25|1156.13|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2312.25||||2312.25|1757.31|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA [1260]|CIGNA PPO [126025]|2312.25||||2312.25|924.9|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2312.25||||2312.25|297|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2312.25||||2312.25|1156.13|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|Self-pay|Self-pay|2312.25||||2312.25|462.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|TML [1980]|TML [198000]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2312.25||||2312.25|899.93|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2312.25||||2312.25|297|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UNICARE [2040]|UNICARE [204000]|2312.25||||2312.25|297|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2312.25||||2312.25|297|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WEB TPA [2115]|WEB TPA [211500]|2312.25||||2312.25|1595.45|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2312.25||||2312.25|0|1757.31|297
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WORKER'S COMP [2125]|TML WC [212537]|2312.25||||2312.25|297|1757.31|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AARP [1000]|AARP [100000]|1660||||1660|297|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA [1015]|AETNA [101529]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMBETTER [2930]|AMBETTER [293000]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1660||||1660|830|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1660||||1660|1195.2|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1660||||1660|830|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1660||||1660|830|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1660||||1660|1261.6|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA [1260]|CIGNA PPO [126025]|1660||||1660|664|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1660||||1660|297|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1660||||1660|830|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|Self-pay|Self-pay|1660||||1660|332|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|TML [1980]|TML [198000]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1660||||1660|646.07|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1660||||1660|297|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNICARE [2040]|UNICARE [204000]|1660||||1660|297|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1660||||1660|297|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WEB TPA [2115]|WEB TPA [211500]|1660||||1660|1145.4|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1660||||1660|0|1261.6|297
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WORKER'S COMP [2125]|TML WC [212537]|1660||||1660|297|1261.6|297
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.5||||3.5||2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.5||||3.5|1.75|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.5||||3.5|1.36|2.66|0.7
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]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.5||||3.5|2.52|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.5||||3.5|1.75|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.5||||3.5|1.75|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.5||||3.5|2.66|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.5||||3.5|2.42|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.5||||3.5|1.4|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.5||||3.5||2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.5||||3.5|2.42|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.5||||3.5|1.75|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.5||||3.5|2.42|2.66|0.7
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]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.5||||3.5|0|2.66|0.7
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]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.5||||3.5|2.42|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.5||||3.5|0.7|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.5||||3.5|2.42|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.5||||3.5|1.36|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.5||||3.5||2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.5||||3.5||2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.5||||3.5||2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.5||||3.5|2.42|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.5||||3.5|0|2.66|0.7
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]|3.5||||3.5|0|2.66|0.7
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.5||||3.5||2.66|0.7
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.88||||1.88||1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.88||||1.88|0.94|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.88||||1.88|1.35|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.88||||1.88|0.94|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.88||||1.88|0.94|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.88||||1.88|1.43|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.88||||1.88|0.75|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.88||||1.88||1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.88||||1.88|0.94|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.88||||1.88|0.38|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.88||||1.88|0.73|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.88||||1.88||1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.88||||1.88||1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.88||||1.88||1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.88||||1.88|1.3|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.88||||1.88|0|1.43|0.38
4855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.88||||1.88||1.43|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.89||||1.89||1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.89||||1.89|0.95|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.89||||1.89|0.74|1.44|0.38
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]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.89||||1.89|1.36|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.89||||1.89|0.95|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.89||||1.89|0.95|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.89||||1.89|1.44|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.89||||1.89|1.3|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.89||||1.89|0.76|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.89||||1.89||1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.89||||1.89|1.3|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.89||||1.89|0.95|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.89||||1.89|1.3|1.44|0.38
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]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.89||||1.89|0|1.44|0.38
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]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.89||||1.89|1.3|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|Self-pay|Self-pay|1.89||||1.89|0.38|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.89||||1.89|1.3|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.89||||1.89|0.74|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.89||||1.89||1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.89||||1.89||1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.89||||1.89||1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.89||||1.89|1.3|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.89||||1.89|0|1.44|0.38
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]|1.89||||1.89|0|1.44|0.38
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.89||||1.89||1.44|0.38
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|23.84||||23.84||18.12|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]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|23.84||||23.84|0|18.12|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]|23.84||||23.84|9.28|18.12|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]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.84||||23.84|0.18|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.84||||23.84|9.28|18.12|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]|23.84||||23.84|0|18.12|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]|23.84||||23.84|17.16|18.12|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]|23.84||||23.84|11.92|18.12|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]|23.84||||23.84|11.92|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.84||||23.84|18.12|18.12|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]|23.84||||23.84|9.28|18.12|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]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.84||||23.84|16.45|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|23.84||||23.84|9.54|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.84||||23.84||18.12|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]|23.84||||23.84|16.45|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.84||||23.84|0.18|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.84||||23.84|16.45|18.12|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]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.84||||23.84|0|18.12|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]|23.84||||23.84|9.28|18.12|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]|23.84||||23.84|0|18.12|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]|23.84||||23.84|0|18.12|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]|23.84||||23.84|9.28|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|23.84||||23.84|16.45|18.12|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]|23.84||||23.84|9.28|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|23.84||||23.84|4.77|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|23.84||||23.84|16.45|18.12|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]|23.84||||23.84|9.28|18.12|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]|23.84||||23.84||18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|23.84||||23.84||18.12|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]|23.84||||23.84||18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|23.84||||23.84|16.45|18.12|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]|23.84||||23.84|0|18.12|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]|23.84||||23.84|0|18.12|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|23.84||||23.84||18.12|0.18
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52||1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.52||||1.52|0.76|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|1.09|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.76|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.76|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.52||||1.52|1.16|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.52||||1.52|0.61|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.52||||1.52||1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.52||||1.52|0.76|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.3|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.59|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52||1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.52||||1.52||1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52||1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.52||||1.52|1.05|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52|0|1.16|0.3
4982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLDOPA 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.52||||1.52||1.16|0.3
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.61||||2.61||1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.61||||2.61|1.31|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.61||||2.61|1.02|1.98|0.52
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]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.61||||2.61|1.88|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.61||||2.61|1.31|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.61||||2.61|1.31|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.61||||2.61|1.98|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.61||||2.61|1.8|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.61||||2.61|1.04|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.61||||2.61||1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.61||||2.61|1.8|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.61||||2.61|1.31|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.61||||2.61|1.8|1.98|0.52
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]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.61||||2.61|0|1.98|0.52
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]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.61||||2.61|1.8|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.61||||2.61|0.52|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.61||||2.61|1.8|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.61||||2.61|1.02|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.61||||2.61||1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.61||||2.61||1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.61||||2.61||1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.61||||2.61|1.8|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.61||||2.61|0|1.98|0.52
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]|2.61||||2.61|0|1.98|0.52
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.61||||2.61||1.98|0.52
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|15.09||||15.09||11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.09||||15.09|0.46|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.09||||15.09|5.87|11.47|0.46
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]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.09||||15.09|10.86|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.09||||15.09|7.55|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.09||||15.09|7.55|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.09||||15.09|11.47|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.09||||15.09|10.41|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|15.09||||15.09|6.04|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.09||||15.09||11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|15.09||||15.09|10.41|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.09||||15.09|0.46|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.09||||15.09|10.41|11.47|0.46
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]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.09||||15.09|0|11.47|0.46
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]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|15.09||||15.09|10.41|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|15.09||||15.09|3.02|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|TML [1980]|TML [198000]|15.09||||15.09|10.41|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.09||||15.09|5.87|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.09||||15.09||11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|15.09||||15.09||11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.09||||15.09||11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|15.09||||15.09|10.41|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.09||||15.09|0|11.47|0.46
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]|15.09||||15.09|0|11.47|0.46
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|15.09||||15.09||11.47|0.46
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|140.19||||140.19|70.1|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|140.19||||140.19|7.54|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|140.19||||140.19|54.56|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|100.94|925.25|7.54
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]|140.19||||140.19|70.1|925.25|7.54
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]|140.19||||140.19|70.1|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|140.19||||140.19|106.54|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|140.19||||140.19|96.73|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|140.19||||140.19|56.08|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|140.19||||140.19|70.1|925.25|7.54
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]|140.19||||140.19|96.73|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|140.19||||140.19|7.54|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|140.19||||140.19|96.73|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|140.19||||140.19|96.73|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|140.19||||140.19|28.04|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TML [1980]|TML [198000]|140.19||||140.19|96.73|925.25|7.54
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]|140.19||||140.19|54.56|925.25|7.54
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]|140.19||||140.19|70.1|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|140.19||||140.19|70.1|925.25|7.54
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]|140.19||||140.19|70.1|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|140.19||||140.19|96.73|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
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]|140.19||||140.19|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|140.19||||140.19|70.1|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AARP [1000]|AARP [100000]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AETNA [1015]|AETNA [101529]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1217.44||||1217.44|7.54|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1217.44||||1217.44|876.56|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1217.44||||1217.44|925.25|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1217.44||||1217.44|486.98|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1217.44||||1217.44|7.54|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|Self-pay|Self-pay|1217.44||||1217.44|243.49|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|TML [1980]|TML [198000]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1217.44||||1217.44|473.83|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|UNICARE [2040]|UNICARE [204000]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1217.44||||1217.44|608.72|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|1217.44||||1217.44|840.03|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1217.44||||1217.44|0|925.25|7.54
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1217.44||||1217.44|608.72|925.25|7.54
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|243.28||||243.28|121.64|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|243.28||||243.28|13.99|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|243.28||||243.28|94.68|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|175.16|184.89|13.99
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]|243.28||||243.28|121.64|184.89|13.99
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]|243.28||||243.28|121.64|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|243.28||||243.28|184.89|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|243.28||||243.28|167.86|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|243.28||||243.28|97.31|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|243.28||||243.28|121.64|184.89|13.99
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]|243.28||||243.28|167.86|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|243.28||||243.28|13.99|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|243.28||||243.28|167.86|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|243.28||||243.28|167.86|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|243.28||||243.28|48.66|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|TML [1980]|TML [198000]|243.28||||243.28|167.86|184.89|13.99
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]|243.28||||243.28|94.68|184.89|13.99
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]|243.28||||243.28|121.64|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|243.28||||243.28|121.64|184.89|13.99
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]|243.28||||243.28|121.64|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|243.28||||243.28|167.86|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
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]|243.28||||243.28|0|184.89|13.99
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|243.28||||243.28|121.64|184.89|13.99
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.74||||14.74|1.4|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.74||||14.74|10.61|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.74||||14.74|11.2|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.74||||14.74|5.9|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.74||||14.74|1.4|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|14.74||||14.74|2.95|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.74||||14.74|5.74|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.74||||14.74|7.37|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.74||||14.74|10.17|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.74||||14.74|0|11.2|1.4
5002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.74||||14.74|7.37|11.2|1.4
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.97||||0.97||0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.97||||0.97|0.49|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.97||||0.97|0.38|0.74|0.19
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]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.97||||0.97|0.7|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.97||||0.97|0.49|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.97||||0.97|0.49|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.97||||0.97|0.74|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.97||||0.97|0.67|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.97||||0.97|0.39|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.97||||0.97||0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.97||||0.97|0.67|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.97||||0.97|0.49|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.97||||0.97|0.67|0.74|0.19
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]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.97||||0.97|0|0.74|0.19
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]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.97||||0.97|0.67|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.97||||0.97|0.19|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.97||||0.97|0.67|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.97||||0.97|0.38|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.97||||0.97||0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.97||||0.97||0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.97||||0.97||0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.97||||0.97|0.67|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.97||||0.97|0|0.74|0.19
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]|0.97||||0.97|0|0.74|0.19
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.97||||0.97||0.74|0.19
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.46||||1.46||1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.46||||1.46|0.73|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.46||||1.46|0.57|1.11|0.29
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]|1.46||||1.46|0|1.11|0.29
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]|1.46||||1.46|1.05|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.46||||1.46|0.73|1.11|0.29
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]|1.46||||1.46|0.73|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.46||||1.46|1.11|1.11|0.29
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]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.46||||1.46|1.01|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.46||||1.46|0.58|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.46||||1.46||1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.46||||1.46|1.01|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.46||||1.46|0.73|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.46||||1.46|1.01|1.11|0.29
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]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.46||||1.46|0|1.11|0.29
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]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.46||||1.46|1.01|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.46||||1.46|0.29|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.46||||1.46|1.01|1.11|0.29
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]|1.46||||1.46|0.57|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.46||||1.46||1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.46||||1.46||1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.46||||1.46||1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.46||||1.46|1.01|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.46||||1.46|0|1.11|0.29
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]|1.46||||1.46|0|1.11|0.29
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.46||||1.46||1.11|0.29
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.32||||5.32||4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.32||||5.32|2.66|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.32||||5.32|2.07|4.04|1.06
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]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.32||||5.32|3.83|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.32||||5.32|2.66|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.32||||5.32|2.66|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.32||||5.32|4.04|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.32||||5.32|3.67|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.32||||5.32|2.13|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.32||||5.32||4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.32||||5.32|3.67|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.32||||5.32|2.66|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.32||||5.32|3.67|4.04|1.06
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]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.32||||5.32|0|4.04|1.06
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]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.32||||5.32|3.67|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|Self-pay|Self-pay|5.32||||5.32|1.06|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.32||||5.32|3.67|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.32||||5.32|2.07|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.32||||5.32||4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.32||||5.32||4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.32||||5.32||4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.32||||5.32|3.67|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.32||||5.32|0|4.04|1.06
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]|5.32||||5.32|0|4.04|1.06
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.32||||5.32||4.04|1.06
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.74||||8.74||6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.74||||8.74|4.37|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.74||||8.74|3.4|6.64|1.75
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]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.74||||8.74|6.29|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.74||||8.74|4.37|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.74||||8.74|4.37|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.74||||8.74|6.64|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.74||||8.74|6.03|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.74||||8.74|3.5|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.74||||8.74||6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.74||||8.74|6.03|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.74||||8.74|4.37|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.74||||8.74|6.03|6.64|1.75
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]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.74||||8.74|0|6.64|1.75
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]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.74||||8.74|6.03|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|Self-pay|Self-pay|8.74||||8.74|1.75|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.74||||8.74|6.03|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.74||||8.74|3.4|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.74||||8.74||6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.74||||8.74||6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.74||||8.74||6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.74||||8.74|6.03|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.74||||8.74|0|6.64|1.75
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]|8.74||||8.74|0|6.64|1.75
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.74||||8.74||6.64|1.75
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|39.6||||39.6||30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|28.51|30.1|7.92
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]|39.6||||39.6|19.8|30.1|7.92
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]|39.6||||39.6|19.8|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6||30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||30.1|7.92
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AARP [1000]|AARP [100000]|5.35||||5.35||4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA [1015]|AETNA [101529]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMBETTER [2930]|AMBETTER [293000]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.35||||5.35|2.68|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.35||||5.35|2.08|4.07|1.07
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]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.35||||5.35|3.85|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.35||||5.35|2.68|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.35||||5.35|2.68|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.35||||5.35|4.07|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.35||||5.35|3.69|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA PPO [126025]|5.35||||5.35|2.14|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.35||||5.35||4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.35||||5.35|3.69|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.35||||5.35|2.68|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.35||||5.35|3.69|4.07|1.07
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]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.35||||5.35|0|4.07|1.07
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]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.35||||5.35|3.69|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|Self-pay|Self-pay|5.35||||5.35|1.07|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|TML [1980]|TML [198000]|5.35||||5.35|3.69|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.35||||5.35|2.08|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.35||||5.35||4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNICARE [2040]|UNICARE [204000]|5.35||||5.35||4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.35||||5.35||4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WEB TPA [2115]|WEB TPA [211500]|5.35||||5.35|3.69|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.35||||5.35|0|4.07|1.07
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]|5.35||||5.35|0|4.07|1.07
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WORKER'S COMP [2125]|TML WC [212537]|5.35||||5.35||4.07|1.07
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AARP [1000]|AARP [100000]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AETNA [1015]|AETNA [101529]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AMBETTER [2930]|AMBETTER [293000]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA [1260]|CIGNA PPO [126025]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|Self-pay|Self-pay|370.75||||370.75|74.15|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|TML [1980]|TML [198000]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UNICARE [2040]|UNICARE [204000]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|370.75||||370.75|185.38|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WEB TPA [2115]|WEB TPA [211500]|370.75||||370.75|255.82|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|370.75||||370.75|0|255.82|74.15
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WORKER'S COMP [2125]|TML WC [212537]|370.75||||370.75|185.38|255.82|74.15
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.13||||6.13||4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.13||||6.13|3.07|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.13||||6.13|2.39|4.66|1.23
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]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.13||||6.13|4.41|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.13||||6.13|3.07|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.13||||6.13|3.07|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.13||||6.13|4.66|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.13||||6.13|4.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.13||||6.13|2.45|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.13||||6.13||4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.13||||6.13|4.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.13||||6.13|3.07|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.13||||6.13|4.23|4.66|1.23
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]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.13||||6.13|0|4.66|1.23
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]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.13||||6.13|4.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|6.13||||6.13|1.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.13||||6.13|4.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.13||||6.13|2.39|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.13||||6.13||4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.13||||6.13||4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.13||||6.13||4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.13||||6.13|4.23|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.13||||6.13|0|4.66|1.23
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]|6.13||||6.13|0|4.66|1.23
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.13||||6.13||4.66|1.23
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.79||||2.79||2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.79||||2.79|1.4|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.79||||2.79|1.09|2.12|0.56
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]|2.79||||2.79|0|2.12|0.56
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]|2.79||||2.79|2.01|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.4|2.12|0.56
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]|2.79||||2.79|1.4|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.79||||2.79|2.12|2.12|0.56
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]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.79||||2.79|1.93|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.79||||2.79|1.12|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.79||||2.79||2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.79||||2.79|1.4|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.79||||2.79|1.93|2.12|0.56
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]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|0|2.12|0.56
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]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.79||||2.79|0.56|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.79||||2.79|1.93|2.12|0.56
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]|2.79||||2.79|1.09|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79||2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.79||||2.79||2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79||2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.79||||2.79|1.93|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79|0|2.12|0.56
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]|2.79||||2.79|0|2.12|0.56
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.79||||2.79||2.12|0.56
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AARP [1000]|AARP [100000]|10.01||||10.01||7.61|2
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]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.01||||10.01|3.9|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.01||||10.01|5.01|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.01||||10.01|3.9|7.61|2
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]|10.01||||10.01|0|7.61|2
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]|10.01||||10.01|7.21|7.61|2
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]|10.01||||10.01|5.01|7.61|2
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]|10.01||||10.01|5.01|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.01||||10.01|7.61|7.61|2
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]|10.01||||10.01|3.9|7.61|2
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]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.01||||10.01|6.91|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.01||||10.01|4|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.01||||10.01||7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.01||||10.01|6.91|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.01||||10.01|5.01|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.01||||10.01|6.91|7.61|2
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]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.01||||10.01|3.9|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.01||||10.01|0|7.61|2
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]|10.01||||10.01|3.9|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.01||||10.01|6.91|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.01||||10.01|3.9|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|Self-pay|Self-pay|10.01||||10.01|2|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|TML [1980]|TML [198000]|10.01||||10.01|6.91|7.61|2
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]|10.01||||10.01|3.9|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.01||||10.01||7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.01||||10.01||7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.01||||10.01||7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.01||||10.01|6.91|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.01||||10.01|0|7.61|2
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]|10.01||||10.01|0|7.61|2
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.01||||10.01||7.61|2
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|151.8||||151.8||115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|151.8||||151.8|75.9|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|151.8||||151.8|109.3|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|151.8||||151.8|75.9|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|151.8||||151.8|75.9|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|151.8||||151.8|115.37|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|151.8||||151.8|60.72|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|151.8||||151.8||115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|151.8||||151.8|75.9|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|151.8||||151.8|30.36|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TML [1980]|TML [198000]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|151.8||||151.8|59.08|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|151.8||||151.8||115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|151.8||||151.8||115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|151.8||||151.8||115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|151.8||||151.8|104.74|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|151.8||||151.8|0|115.37|30.36
5333|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|151.8||||151.8||115.37|30.36
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AARP [1000]|AARP [100000]|299.1||||299.1||227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA [1015]|AETNA [101529]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMBETTER [2930]|AMBETTER [293000]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|299.1||||299.1|149.55|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299.1||||299.1|215.35|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299.1||||299.1|149.55|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299.1||||299.1|149.55|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|299.1||||299.1|227.32|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA [1260]|CIGNA PPO [126025]|299.1||||299.1|119.64|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|299.1||||299.1||227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|299.1||||299.1|149.55|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|Self-pay|Self-pay|299.1||||299.1|59.82|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|TML [1980]|TML [198000]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299.1||||299.1|116.41|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299.1||||299.1||227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNICARE [2040]|UNICARE [204000]|299.1||||299.1||227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299.1||||299.1||227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WEB TPA [2115]|WEB TPA [211500]|299.1||||299.1|206.38|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299.1||||299.1|0|227.32|59.82
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]|299.1||||299.1|0|227.32|59.82
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WORKER'S COMP [2125]|TML WC [212537]|299.1||||299.1||227.32|59.82
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|208.96||||208.96|104.48|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|208.96||||208.96|81.33|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|208.96||||208.96|15.52|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|208.96||||208.96|81.33|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
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]|208.96||||208.96|150.45|158.81|15.52
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]|208.96||||208.96|104.48|158.81|15.52
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]|208.96||||208.96|104.48|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|208.96||||208.96|158.81|158.81|15.52
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]|208.96||||208.96|81.33|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|208.96||||208.96|144.18|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|208.96||||208.96|83.58|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|208.96||||208.96|104.48|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|208.96||||208.96|144.18|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|208.96||||208.96|15.52|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|208.96||||208.96|144.18|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|208.96||||208.96|0|158.81|15.52
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]|208.96||||208.96|81.33|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|208.96||||208.96|0|158.81|15.52
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]|208.96||||208.96|81.33|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|208.96||||208.96|144.18|158.81|15.52
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]|208.96||||208.96|81.33|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|208.96||||208.96|41.79|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|208.96||||208.96|144.18|158.81|15.52
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]|208.96||||208.96|81.33|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|208.96||||208.96|104.48|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|208.96||||208.96|104.48|158.81|15.52
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]|208.96||||208.96|104.48|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|208.96||||208.96|144.18|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
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]|208.96||||208.96|0|158.81|15.52
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|208.96||||208.96|104.48|158.81|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AARP [1000]|AARP [100000]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AMBETTER [2930]|AMBETTER [293000]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|435.6||||435.6|15.52|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|435.6||||435.6|313.63|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|435.6||||435.6|331.06|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA PPO [126025]|435.6||||435.6|174.24|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|435.6||||435.6|15.52|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|Self-pay|Self-pay|435.6||||435.6|87.12|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|TML [1980]|TML [198000]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|435.6||||435.6|169.54|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|UNICARE [2040]|UNICARE [204000]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|435.6||||435.6|217.8|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|WEB TPA [2115]|WEB TPA [211500]|435.6||||435.6|300.56|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|435.6||||435.6|0|331.06|15.52
5374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 1 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TML WC [212537]|435.6||||435.6|217.8|331.06|15.52
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.88||||2.88||2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.88||||2.88|1.44|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.88||||2.88|1.12|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.88||||2.88|2.07|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.88||||2.88|1.44|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.88||||2.88|1.44|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.88||||2.88|2.19|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.88||||2.88|1.99|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.88||||2.88|1.15|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.88||||2.88||2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.88||||2.88|1.99|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.88||||2.88|1.44|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.88||||2.88|1.99|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.88||||2.88|0|2.19|0.58
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]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.88||||2.88|1.99|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.88||||2.88|0.58|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.88||||2.88|1.99|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.88||||2.88|1.12|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.88||||2.88||2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.88||||2.88||2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.88||||2.88||2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.88||||2.88|1.99|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.88||||2.88|0|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.88||||2.88||2.19|0.58
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]|673.86||||673.86||512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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|AMBETTER [2930]|AMBETTER [293000]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|673.86||||673.86|336.93|512.13|134.77
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 MEDICAID [1165]|BCBS MEDICAID [116504]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|485.18|512.13|134.77
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]|673.86||||673.86|336.93|512.13|134.77
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]|673.86||||673.86|336.93|512.13|134.77
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 TRADITIONAL OF TEXAS [115503]|673.86||||673.86|512.13|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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 - GREAT WEST [126009]|673.86||||673.86|464.96|512.13|134.77
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 PPO [126025]|673.86||||673.86|269.54|512.13|134.77
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|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|673.86||||673.86||512.13|134.77
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]|673.86||||673.86|464.96|512.13|134.77
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|673.86||||673.86|336.93|512.13|134.77
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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|673.86||||673.86|464.96|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86|464.96|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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|673.86||||673.86|134.77|512.13|134.77
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|TML [1980]|TML [198000]|673.86||||673.86|464.96|512.13|134.77
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]|673.86||||673.86|262.27|512.13|134.77
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]|673.86||||673.86||512.13|134.77
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|UNICARE [2040]|UNICARE [204000]|673.86||||673.86||512.13|134.77
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]|673.86||||673.86||512.13|134.77
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|WEB TPA [2115]|WEB TPA [211500]|673.86||||673.86|464.96|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|673.86||||673.86|0|512.13|134.77
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]|TML WC [212537]|673.86||||673.86||512.13|134.77
5510001|EAP||HH RN INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510001|EAP||HH RN INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510002|EAP||HH RN ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AARP [1000]|AARP [100000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA [1015]|AETNA [101529]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMBETTER [2930]|AMBETTER [293000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|92.02|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|63.91|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||127.81|97.14|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA [1260]|CIGNA PPO [126025]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|Self-pay|Self-pay|||||127.81|25.56|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|TML [1980]|TML [198000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNICARE [2040]|UNICARE [204000]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WEB TPA [2115]|WEB TPA [211500]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81|0|97.14|25.56
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WORKER'S COMP [2125]|TML WC [212537]|||||127.81|0|97.14|25.56
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59||0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.59||||0.59|0.3|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.42|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.3|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.3|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.59||||0.59|0.45|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.59||||0.59|0.24|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.59||||0.59||0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.59||||0.59|0.3|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.12|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.23|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59||0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.59||||0.59||0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59||0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.59||||0.59|0.41|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59|0|0.45|0.12
5539|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.59||||0.59||0.45|0.12
5600001|EAP||HH MSW INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|147.51|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|102.44|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|102.44|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||204.87|155.7|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|Self-pay|Self-pay|||||204.87|40.97|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|TML [1980]|TML [198000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UNICARE [2040]|UNICARE [204000]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87|0|155.7|40.97
5600001|EAP||HH MSW INITIAL VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||204.87|0|155.7|40.97
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|10.46||||10.46||7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.46||||10.46|5.23|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.46||||10.46|7.53|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.46||||10.46|5.23|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.46||||10.46|5.23|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.46||||10.46|7.95|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|10.46||||10.46|4.18|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.46||||10.46||7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.46||||10.46|5.23|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|10.46||||10.46|2.09|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|TML [1980]|TML [198000]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.46||||10.46|4.07|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.46||||10.46||7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNICARE [2040]|UNICARE [204000]|10.46||||10.46||7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.46||||10.46||7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|10.46||||10.46|7.22|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.46||||10.46|0|7.95|2.09
5601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|10.46||||10.46||7.95|2.09
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|18.12||||18.12||13.77|3.62
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]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.12||||18.12|7.05|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.12||||18.12|9.06|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.12||||18.12|7.05|13.77|3.62
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]|18.12||||18.12|0|13.77|3.62
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]|18.12||||18.12|13.05|13.77|3.62
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]|18.12||||18.12|9.06|13.77|3.62
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]|18.12||||18.12|9.06|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.12||||18.12|13.77|13.77|3.62
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]|18.12||||18.12|7.05|13.77|3.62
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]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.12||||18.12|12.5|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.12||||18.12|7.25|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.12||||18.12||13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.12||||18.12|12.5|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.12||||18.12|9.06|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.12||||18.12|12.5|13.77|3.62
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]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.12||||18.12|7.05|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.12||||18.12|0|13.77|3.62
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]|18.12||||18.12|7.05|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.12||||18.12|12.5|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.12||||18.12|7.05|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|18.12||||18.12|3.62|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|TML [1980]|TML [198000]|18.12||||18.12|12.5|13.77|3.62
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]|18.12||||18.12|7.05|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.12||||18.12||13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.12||||18.12||13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.12||||18.12||13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.12||||18.12|12.5|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.12||||18.12|0|13.77|3.62
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]|18.12||||18.12|0|13.77|3.62
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.12||||18.12||13.77|3.62
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AARP [1000]|AARP [100000]|29.1||||29.1||22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA [1015]|AETNA [101529]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMBETTER [2930]|AMBETTER [293000]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|29.1||||29.1|14.55|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|29.1||||29.1|11.33|22.12|5.82
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]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.1||||29.1|20.95|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.1||||29.1|14.55|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.1||||29.1|14.55|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|29.1||||29.1|22.12|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA [1260]|CIGNA - GREAT WEST [126009]|29.1||||29.1|20.08|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA [1260]|CIGNA PPO [126025]|29.1||||29.1|11.64|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|29.1||||29.1||22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|29.1||||29.1|20.08|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|29.1||||29.1|14.55|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|29.1||||29.1|20.08|22.12|5.82
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]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.1||||29.1|0|22.12|5.82
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]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|29.1||||29.1|20.08|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|Self-pay|Self-pay|29.1||||29.1|5.82|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|TML [1980]|TML [198000]|29.1||||29.1|20.08|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.1||||29.1|11.33|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.1||||29.1||22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNICARE [2040]|UNICARE [204000]|29.1||||29.1||22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.1||||29.1||22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WEB TPA [2115]|WEB TPA [211500]|29.1||||29.1|20.08|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.1||||29.1|0|22.12|5.82
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]|29.1||||29.1|0|22.12|5.82
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WORKER'S COMP [2125]|TML WC [212537]|29.1||||29.1||22.12|5.82
5610001|EAP||HH MSW ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|147.51|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|102.44|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|102.44|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||204.87|155.7|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|Self-pay|Self-pay|||||204.87|40.97|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|TML [1980]|TML [198000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87|0|155.7|40.97
5610001|EAP||HH MSW ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||204.87|0|155.7|40.97
5710001|EAP||HH HHA VISIT|1|AARP [1000]|AARP [100000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|AETNA [1015]|AETNA [101529]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||57.88|41.67|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||57.88|28.94|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||57.88|28.94|43.99|11.58
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||57.88|43.99|43.99|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|Self-pay|Self-pay|||||57.88|11.58|43.99|11.58
5710001|EAP||HH HHA VISIT|1|TML [1980]|TML [198000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|UNICARE [2040]|UNICARE [204000]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||57.88|0|43.99|11.58
5710001|EAP||HH HHA VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||57.88|0|43.99|11.58
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|184.74||||184.74||140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.74||||184.74|92.37|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184.74||||184.74|133.01|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184.74||||184.74|92.37|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184.74||||184.74|92.37|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.74||||184.74|140.4|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|184.74||||184.74|73.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.74||||184.74||140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.74||||184.74|92.37|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|Self-pay|Self-pay|184.74||||184.74|36.95|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|TML [1980]|TML [198000]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184.74||||184.74|71.9|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.74||||184.74||140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|184.74||||184.74||140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184.74||||184.74||140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|184.74||||184.74|127.47|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184.74||||184.74|0|140.4|36.95
5749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|184.74||||184.74||140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|184.74||||184.74||140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.74||||184.74|71.9|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.74||||184.74|92.37|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.74||||184.74|71.9|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
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]|184.74||||184.74|133.01|140.4|36.95
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]|184.74||||184.74|92.37|140.4|36.95
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]|184.74||||184.74|92.37|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.74||||184.74|140.4|140.4|36.95
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]|184.74||||184.74|71.9|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.74||||184.74|127.47|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|184.74||||184.74|73.9|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.74||||184.74||140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|184.74||||184.74|127.47|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.74||||184.74|92.37|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.74||||184.74|127.47|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.74||||184.74|0|140.4|36.95
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]|184.74||||184.74|71.9|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.74||||184.74|0|140.4|36.95
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]|184.74||||184.74|71.9|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|184.74||||184.74|127.47|140.4|36.95
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]|184.74||||184.74|71.9|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|Self-pay|Self-pay|184.74||||184.74|36.95|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|184.74||||184.74|127.47|140.4|36.95
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]|184.74||||184.74|71.9|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.74||||184.74||140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|184.74||||184.74||140.4|36.95
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]|184.74||||184.74||140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|184.74||||184.74|127.47|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
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]|184.74||||184.74|0|140.4|36.95
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|184.74||||184.74||140.4|36.95
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|11.09||||11.09||127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.09||||11.09|4.32|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.09||||11.09|5.55|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.09||||11.09|4.32|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
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]|11.09||||11.09|7.98|127.61|2.22
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]|11.09||||11.09|5.55|127.61|2.22
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]|11.09||||11.09|5.55|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.09||||11.09|8.43|127.61|2.22
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]|11.09||||11.09|4.32|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.09||||11.09|7.65|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|11.09||||11.09|4.44|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.09||||11.09||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.09||||11.09|7.65|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.09||||11.09|5.55|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.09||||11.09|7.65|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.09||||11.09|0|127.61|2.22
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]|11.09||||11.09|4.32|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.09||||11.09|0|127.61|2.22
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]|11.09||||11.09|4.32|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.09||||11.09|7.65|127.61|2.22
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]|11.09||||11.09|4.32|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|11.09||||11.09|2.22|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|11.09||||11.09|7.65|127.61|2.22
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]|11.09||||11.09|4.32|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.09||||11.09||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|11.09||||11.09||127.61|2.22
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]|11.09||||11.09||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|11.09||||11.09|7.65|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
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]|11.09||||11.09|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|11.09||||11.09||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|167.91||||167.91||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMBETTER [2930]|AMBETTER [293000]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|167.91||||167.91|83.96|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|167.91||||167.91|120.9|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|167.91||||167.91|83.96|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|167.91||||167.91|83.96|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|167.91||||167.91|127.61|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA PPO [126025]|167.91||||167.91|67.16|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|167.91||||167.91||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|167.91||||167.91|83.96|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|167.91||||167.91|33.58|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|TML [1980]|TML [198000]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|167.91||||167.91|65.35|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167.91||||167.91||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UNICARE [2040]|UNICARE [204000]|167.91||||167.91||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167.91||||167.91||127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WEB TPA [2115]|WEB TPA [211500]|167.91||||167.91|115.86|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|167.91||||167.91|0|127.61|2.22
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TML WC [212537]|167.91||||167.91||127.61|2.22
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]|886.45||||886.45||673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|886.45||||886.45|443.23|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|638.24|673.7|177.29
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]|886.45||||886.45|443.23|673.7|177.29
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]|886.45||||886.45|443.23|673.7|177.29
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 TRADITIONAL OF TEXAS [115503]|886.45||||886.45|673.7|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|886.45||||886.45|611.65|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|886.45||||886.45|354.58|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|886.45||||886.45||673.7|177.29
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]|886.45||||886.45|611.65|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|886.45||||886.45|443.23|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|886.45||||886.45|611.65|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45|611.65|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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|886.45||||886.45|177.29|673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|886.45||||886.45|611.65|673.7|177.29
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]|886.45||||886.45|345.01|673.7|177.29
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]|886.45||||886.45||673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|886.45||||886.45||673.7|177.29
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]|886.45||||886.45||673.7|177.29
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|886.45||||886.45|611.65|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|886.45||||886.45|0|673.7|177.29
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]|TML WC [212537]|886.45||||886.45||673.7|177.29
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|658.75||||658.75||500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|658.75||||658.75|329.38|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|658.75||||658.75|474.3|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|658.75||||658.75|329.38|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|658.75||||658.75|329.38|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|658.75||||658.75|500.65|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|658.75||||658.75|263.5|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|658.75||||658.75||500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|658.75||||658.75|329.38|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|658.75||||658.75|131.75|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|658.75||||658.75|256.39|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|658.75||||658.75||500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|658.75||||658.75||500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|658.75||||658.75||500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|658.75||||658.75|454.54|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|658.75||||658.75|0|500.65|131.75
5755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|658.75||||658.75||500.65|131.75
5800001|EAP||HH INITIAL RT VISIT|1|AARP [1000]|AARP [100000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|AETNA [1015]|AETNA [101529]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|108|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|75|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|75|114|30
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||150|114|114|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|Self-pay|Self-pay|||||150|30|114|30
5800001|EAP||HH INITIAL RT VISIT|1|TML [1980]|TML [198000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|UNICARE [2040]|UNICARE [204000]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150|0|114|30
5800001|EAP||HH INITIAL RT VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMBETTER [2930]|AMBETTER [293000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|108|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|75|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|75|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|||||150|114|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA [1260]|CIGNA PPO [126025]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|Self-pay|Self-pay|||||150|30|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|TML [1980]|TML [198000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|UNICARE [2040]|UNICARE [204000]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|WEB TPA [2115]|WEB TPA [211500]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150|0|114|30
5810001|EAP||HH RT ROUTINE VISIT|1|WORKER'S COMP [2125]|TML WC [212537]|||||150|0|114|30
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|205.92||||205.92||156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.92||||205.92|80.14|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205.92||||205.92|8.88|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205.92||||205.92|80.14|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
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]|205.92||||205.92|148.26|156.5|8.88
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]|205.92||||205.92|102.96|156.5|8.88
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]|205.92||||205.92|102.96|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205.92||||205.92|156.5|156.5|8.88
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]|205.92||||205.92|80.14|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205.92||||205.92|142.08|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|205.92||||205.92|82.37|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205.92||||205.92||156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|205.92||||205.92|142.08|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205.92||||205.92|8.88|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205.92||||205.92|142.08|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.92||||205.92|0|156.5|8.88
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]|205.92||||205.92|80.14|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.92||||205.92|0|156.5|8.88
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]|205.92||||205.92|80.14|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|205.92||||205.92|142.08|156.5|8.88
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]|205.92||||205.92|80.14|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|205.92||||205.92|41.18|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|205.92||||205.92|142.08|156.5|8.88
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]|205.92||||205.92|80.14|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.92||||205.92||156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|205.92||||205.92||156.5|8.88
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]|205.92||||205.92||156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|205.92||||205.92|142.08|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
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]|205.92||||205.92|0|156.5|8.88
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|205.92||||205.92||156.5|8.88
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.92||||7.92||6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.92||||7.92|3.96|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.92||||7.92|3.08|6.02|1.58
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]|7.92||||7.92|0|6.02|1.58
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]|7.92||||7.92|5.7|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.92||||7.92|3.96|6.02|1.58
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]|7.92||||7.92|3.96|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.92||||7.92|6.02|6.02|1.58
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]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.92||||7.92|5.46|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.92||||7.92|3.17|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.92||||7.92||6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.92||||7.92|5.46|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.92||||7.92|3.96|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.92||||7.92|5.46|6.02|1.58
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]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.92||||7.92|0|6.02|1.58
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]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.92||||7.92|5.46|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|7.92||||7.92|1.58|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.92||||7.92|5.46|6.02|1.58
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]|7.92||||7.92|3.08|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.92||||7.92||6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.92||||7.92||6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.92||||7.92||6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.92||||7.92|5.46|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.92||||7.92|0|6.02|1.58
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]|7.92||||7.92|0|6.02|1.58
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.92||||7.92||6.02|1.58
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.36||||5.36||4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.36||||5.36|2.09|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.36||||5.36|2.68|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.36||||5.36|2.09|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
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]|5.36||||5.36|3.86|4.07|1.07
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]|5.36||||5.36|2.68|4.07|1.07
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]|5.36||||5.36|2.68|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.36||||5.36|4.07|4.07|1.07
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]|5.36||||5.36|2.09|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.36||||5.36|3.7|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.36||||5.36|2.14|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.36||||5.36||4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.36||||5.36|3.7|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.36||||5.36|2.68|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.36||||5.36|3.7|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.36||||5.36|0|4.07|1.07
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]|5.36||||5.36|2.09|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.36||||5.36|0|4.07|1.07
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]|5.36||||5.36|2.09|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.36||||5.36|3.7|4.07|1.07
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]|5.36||||5.36|2.09|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|Self-pay|Self-pay|5.36||||5.36|1.07|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.36||||5.36|3.7|4.07|1.07
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]|5.36||||5.36|2.09|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.36||||5.36||4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.36||||5.36||4.07|1.07
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]|5.36||||5.36||4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.36||||5.36|3.7|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
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]|5.36||||5.36|0|4.07|1.07
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.36||||5.36||4.07|1.07
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AARP [1000]|AARP [100000]|65.54||||65.54||49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA [1015]|AETNA [101529]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMBETTER [2930]|AMBETTER [293000]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|65.54||||65.54|32.77|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|65.54||||65.54|25.51|49.81|13.11
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]|65.54||||65.54|0|49.81|13.11
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]|65.54||||65.54|47.19|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.54||||65.54|32.77|49.81|13.11
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]|65.54||||65.54|32.77|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|65.54||||65.54|49.81|49.81|13.11
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]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|65.54||||65.54|45.22|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA PPO [126025]|65.54||||65.54|26.22|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|65.54||||65.54||49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|65.54||||65.54|45.22|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|65.54||||65.54|32.77|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.54||||65.54|45.22|49.81|13.11
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]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.54||||65.54|0|49.81|13.11
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]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|65.54||||65.54|45.22|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|Self-pay|Self-pay|65.54||||65.54|13.11|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|TML [1980]|TML [198000]|65.54||||65.54|45.22|49.81|13.11
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]|65.54||||65.54|25.51|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.54||||65.54||49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNICARE [2040]|UNICARE [204000]|65.54||||65.54||49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.54||||65.54||49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WEB TPA [2115]|WEB TPA [211500]|65.54||||65.54|45.22|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.54||||65.54|0|49.81|13.11
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]|65.54||||65.54|0|49.81|13.11
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TML WC [212537]|65.54||||65.54||49.81|13.11
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|546.62||||546.62||415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|546.62||||546.62|273.31|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546.62||||546.62|393.57|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546.62||||546.62|273.31|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546.62||||546.62|273.31|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|546.62||||546.62|415.43|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|546.62||||546.62|218.65|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|546.62||||546.62||415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|546.62||||546.62|273.31|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|546.62||||546.62|109.32|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546.62||||546.62|212.74|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546.62||||546.62||415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|546.62||||546.62||415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546.62||||546.62||415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|546.62||||546.62|377.17|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546.62||||546.62|0|415.43|109.32
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|546.62||||546.62||415.43|109.32
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AARP [1000]|AARP [100000]|671.62||||671.62||510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AETNA [1015]|AETNA [101529]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMBETTER [2930]|AMBETTER [293000]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|671.62||||671.62|1.43|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|671.62||||671.62|483.57|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|671.62||||671.62|335.81|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|671.62||||671.62|335.81|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|671.62||||671.62|510.43|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|CIGNA [1260]|CIGNA PPO [126025]|671.62||||671.62|268.65|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|671.62||||671.62||510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|GROUP PENSION ADMIN [1450]|GPA [145000]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|671.62||||671.62|1.43|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|PHCS [1780]|PHCS MULTIPLAN [178000]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|Self-pay|Self-pay|671.62||||671.62|134.32|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|TML [1980]|TML [198000]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|671.62||||671.62|261.39|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|671.62||||671.62||510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UNICARE [2040]|UNICARE [204000]|671.62||||671.62||510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|671.62||||671.62||510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WEB TPA [2115]|WEB TPA [211500]|671.62||||671.62|463.42|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|671.62||||671.62|0|510.43|1.43
6085|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION|20 Million Units|WORKER'S COMP [2125]|TML WC [212537]|671.62||||671.62||510.43|1.43
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.64||||2.64||2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|1.03|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|1.03|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|1.9|2.01|0.53
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]|2.64||||2.64|1.32|2.01|0.53
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]|2.64||||2.64|1.32|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|2.01|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64||2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|1.03|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|1.03|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.64||||2.64|0.53|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.64||||2.64|1.82|2.01|0.53
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]|2.64||||2.64|1.03|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64||2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.64||||2.64||2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64||2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64|0|2.01|0.53
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]|2.64||||2.64|0|2.01|0.53
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64||2.01|0.53
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|7834||||7834|686.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7834||||7834|478.56|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7834||||7834|641.25|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7834||||7834|5640.48|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7834||||7834|3917|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7834||||7834|3917|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7834||||7834|5953.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7834||||7834|5405.46|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|7834||||7834|1676.2|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7834||||7834|686.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7834||||7834|5405.46|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7834||||7834|478.56|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7834||||7834|5405.46|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7834||||7834|5405.46|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|Self-pay|Self-pay|7834||||7834|1566.8|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|TML [1980]|TML [198000]|7834||||7834|5405.46|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7834||||7834|641.25|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7834||||7834|686.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|7834||||7834|686.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7834||||7834|686.84|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|7834||||7834|5405.46|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AARP [1000]|AARP [100000]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AETNA [1015]|AETNA [101529]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AMBETTER [2930]|AMBETTER [293000]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7834||||7834|478.56|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7834||||7834|725.63|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7834||||7834|5640.48|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7834||||7834|3917|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7834||||7834|3917|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7834||||7834|5953.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7834||||7834|5405.46|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA [1260]|CIGNA PPO [126025]|7834||||7834|1676.2|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7834||||7834|5405.46|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7834||||7834|478.56|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7834||||7834|5405.46|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7834||||7834|5405.46|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|Self-pay|Self-pay|7834||||7834|1566.8|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|TML [1980]|TML [198000]|7834||||7834|5405.46|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7834||||7834|725.63|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UNICARE [2040]|UNICARE [204000]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7834||||7834|686.84|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|WEB TPA [2115]|WEB TPA [211500]|7834||||7834|5405.46|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|WORKER'S COMP [2125]|TML WC [212537]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AARP [1000]|AARP [100000]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7834||||7834|478.56|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7834||||7834|708.19|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|5640.48|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7834||||7834|3917|5953.84|478.56
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]|7834||||7834|3917|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7834||||7834|5953.84|5953.84|478.56
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]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7834||||7834|5405.46|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|7834||||7834|1676.2|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7834||||7834|5405.46|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7834||||7834|478.56|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7834||||7834|5405.46|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7834||||7834|5405.46|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|Self-pay|Self-pay|7834||||7834|1566.8|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|TML [1980]|TML [198000]|7834||||7834|5405.46|5953.84|478.56
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]|7834||||7834|708.19|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7834||||7834|686.84|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|7834||||7834|5405.46|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7834||||7834|0|5953.84|478.56
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]|7834||||7834|0|5953.84|478.56
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|7834||||7834|686.84|5953.84|478.56
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AARP [1000]|AARP [100000]|666||||666|423.11|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|666||||666|299.17|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|666||||666|369.37|666|133.2
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]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|479.52|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|333|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|666||||666|506.16|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|666||||666|459.54|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|666||||666|666|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|666||||666|423.11|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|666||||666|299.17|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|666||||666|459.54|666|133.2
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]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|0|666|133.2
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]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|Self-pay|Self-pay|666||||666|133.2|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|TML [1980]|TML [198000]|666||||666|459.54|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|369.37|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666|423.11|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|666||||666|423.11|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666|423.11|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|666||||666|459.54|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666|0|666|133.2
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]|666||||666|0|666|133.2
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|666||||666|423.11|666|133.2
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|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 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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|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 MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|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|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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|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|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01|0|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|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AARP [1000]|AARP [100000]|4715||||4715|423.11|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4715||||4715|299.17|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4715||||4715|347.97|3583.4|299.17
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]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4715||||4715|3394.8|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4715||||4715|2357.5|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4715||||4715|2357.5|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4715||||4715|3583.4|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4715||||4715|3253.35|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|4715||||4715|1009.22|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4715||||4715|423.11|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4715||||4715|3253.35|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4715||||4715|299.17|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4715||||4715|3253.35|3583.4|299.17
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]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4715||||4715|0|3583.4|299.17
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]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4715||||4715|3253.35|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|Self-pay|Self-pay|4715||||4715|943|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|TML [1980]|TML [198000]|4715||||4715|3253.35|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4715||||4715|347.97|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4715||||4715|423.11|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|4715||||4715|423.11|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4715||||4715|423.11|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|4715||||4715|3253.35|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4715||||4715|0|3583.4|299.17
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]|4715||||4715|0|3583.4|299.17
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|4715||||4715|423.11|3583.4|299.17
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AARP [1000]|AARP [100000]|5611||||5611||4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AETNA [1015]|AETNA [101529]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5611||||5611|478.56|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5611||||5611|4039.92|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5611||||5611|2805.5|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5611||||5611|2805.5|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5611||||5611|4264.36|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5611||||5611|1676.2|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5611||||5611||4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5611||||5611|478.56|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|Self-pay|Self-pay|5611||||5611|1122.2|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|TML [1980]|TML [198000]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5611||||5611|401.86|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5611||||5611||4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5611||||5611||4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5611||||5611||4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5611||||5611|3871.59|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5611||||5611|0|4264.36|401.86
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]|5611||||5611|0|4264.36|401.86
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5611||||5611||4264.36|401.86
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|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 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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|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 MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|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|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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|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|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01|0|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|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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]|4735||||4735|423.11|3598.6|299.17
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]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4735||||4735|338.42|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4735||||4735|299.17|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4735||||4735|338.42|3598.6|299.17
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]|4735||||4735|0|3598.6|299.17
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]|4735||||4735|3409.2|3598.6|299.17
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]|4735||||4735|2367.5|3598.6|299.17
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]|4735||||4735|2367.5|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4735||||4735|3598.6|3598.6|299.17
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]|4735||||4735|338.42|3598.6|299.17
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]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4735||||4735|3267.15|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|4735||||4735|1009.22|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4735||||4735|423.11|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4735||||4735|3267.15|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4735||||4735|299.17|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4735||||4735|3267.15|3598.6|299.17
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]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4735||||4735|338.42|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4735||||4735|0|3598.6|299.17
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]|4735||||4735|338.42|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4735||||4735|3267.15|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4735||||4735|338.42|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|Self-pay|Self-pay|4735||||4735|947|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|TML [1980]|TML [198000]|4735||||4735|3267.15|3598.6|299.17
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]|4735||||4735|338.42|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4735||||4735|423.11|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|4735||||4735|423.11|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4735||||4735|423.11|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|4735||||4735|3267.15|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4735||||4735|0|3598.6|299.17
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]|4735||||4735|0|3598.6|299.17
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|4735||||4735|423.11|3598.6|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|5791||||5791|423.11|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5791||||5791|299.17|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5791||||5791|4169.52|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5791||||5791|2895.5|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5791||||5791|2895.5|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5791||||5791|4401.16|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5791||||5791|1009.22|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5791||||5791|423.11|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5791||||5791|299.17|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|Self-pay|Self-pay|5791||||5791|1158.2|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|TML [1980]|TML [198000]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5791||||5791|369.37|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5791||||5791|423.11|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5791||||5791|423.11|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5791||||5791|423.11|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5791||||5791|3995.79|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5791||||5791|0|4401.16|299.17
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5791||||5791|423.11|4401.16|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AARP [1000]|AARP [100000]|5542.5||||5542.5|423.11|4212.3|299.17
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]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMBETTER [2930]|AMBETTER [293000]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5542.5||||5542.5|369.37|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5542.5||||5542.5|299.17|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5542.5||||5542.5|369.37|4212.3|299.17
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]|5542.5||||5542.5|0|4212.3|299.17
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]|5542.5||||5542.5|3990.6|4212.3|299.17
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]|5542.5||||5542.5|2771.25|4212.3|299.17
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]|5542.5||||5542.5|2771.25|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5542.5||||5542.5|4212.3|4212.3|299.17
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]|5542.5||||5542.5|369.37|4212.3|299.17
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]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5542.5||||5542.5|3824.33|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA PPO [126025]|5542.5||||5542.5|1009.22|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5542.5||||5542.5|423.11|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5542.5||||5542.5|3824.33|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5542.5||||5542.5|299.17|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5542.5||||5542.5|3824.33|4212.3|299.17
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]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5542.5||||5542.5|369.37|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5542.5||||5542.5|0|4212.3|299.17
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]|5542.5||||5542.5|369.37|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5542.5||||5542.5|3824.33|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5542.5||||5542.5|369.37|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|Self-pay|Self-pay|5542.5||||5542.5|1108.5|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|TML [1980]|TML [198000]|5542.5||||5542.5|3824.33|4212.3|299.17
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]|5542.5||||5542.5|369.37|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5542.5||||5542.5|423.11|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNICARE [2040]|UNICARE [204000]|5542.5||||5542.5|423.11|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5542.5||||5542.5|423.11|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WEB TPA [2115]|WEB TPA [211500]|5542.5||||5542.5|3824.33|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5542.5||||5542.5|0|4212.3|299.17
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]|5542.5||||5542.5|0|4212.3|299.17
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WORKER'S COMP [2125]|TML WC [212537]|5542.5||||5542.5|423.11|4212.3|299.17
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01|0|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|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WEB TPA [2115]|WEB TPA [211500]|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|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|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|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 MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|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 [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|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 COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|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|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|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMBETTER [2930]|AMBETTER [293000]|0.01||||0.01|0|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.01||||0.01|0|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|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|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA PPO [126025]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.01||||0.01|0|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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|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|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|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|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|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|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|TML [1980]|TML [198000]|0.01||||0.01|0.01|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNICARE [2040]|UNICARE [204000]|0.01||||0.01|0|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WEB TPA [2115]|WEB TPA [211500]|0.01||||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|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|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TML WC [212537]|0.01||||0.01|0|0.01|0.01
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.56||||10.56||8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.56||||10.56|5.28|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.56||||10.56|4.11|8.03|2.11
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]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.56||||10.56|7.6|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.56||||10.56|5.28|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.56||||10.56|5.28|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.56||||10.56|8.03|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.56||||10.56|7.29|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.56||||10.56|4.22|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.56||||10.56||8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.56||||10.56|7.29|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.56||||10.56|5.28|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.56||||10.56|7.29|8.03|2.11
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]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.56||||10.56|0|8.03|2.11
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]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.56||||10.56|7.29|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|10.56||||10.56|2.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.56||||10.56|7.29|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.56||||10.56|4.11|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.56||||10.56||8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.56||||10.56||8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.56||||10.56||8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.56||||10.56|7.29|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.56||||10.56|0|8.03|2.11
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]|10.56||||10.56|0|8.03|2.11
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.56||||10.56||8.03|2.11
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]|942.79||||942.79||716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AMBETTER [2930]|AMBETTER [293000]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|942.79||||942.79|471.4|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|678.81|716.52|5.14
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]|942.79||||942.79|471.4|716.52|5.14
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]|942.79||||942.79|471.4|716.52|5.14
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 TRADITIONAL OF TEXAS [115503]|942.79||||942.79|716.52|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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 - GREAT WEST [126009]|942.79||||942.79|650.53|716.52|5.14
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 PPO [126025]|942.79||||942.79|377.12|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|942.79||||942.79||716.52|5.14
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]|942.79||||942.79|650.53|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|942.79||||942.79|471.4|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|942.79||||942.79|650.53|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79|650.53|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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|942.79||||942.79|188.56|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|TML [1980]|TML [198000]|942.79||||942.79|650.53|716.52|5.14
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]|942.79||||942.79|366.93|716.52|5.14
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]|942.79||||942.79||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UNICARE [2040]|UNICARE [204000]|942.79||||942.79||716.52|5.14
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]|942.79||||942.79||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|WEB TPA [2115]|WEB TPA [211500]|942.79||||942.79|650.53|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|942.79||||942.79|0|716.52|5.14
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]|TML WC [212537]|942.79||||942.79||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AARP [1000]|AARP [100000]|25.68||||25.68||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AETNA [1015]|AETNA [101529]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|25.68||||25.68|12.84|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.68||||25.68|18.49|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.68||||25.68|12.84|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.68||||25.68|12.84|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|25.68||||25.68|19.52|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|25.68||||25.68|10.27|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|25.68||||25.68||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|25.68||||25.68|12.84|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|Self-pay|Self-pay|25.68||||25.68|5.14|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|TML [1980]|TML [198000]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.68||||25.68|9.99|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.68||||25.68||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|25.68||||25.68||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.68||||25.68||716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|25.68||||25.68|17.72|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.68||||25.68|0|716.52|5.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|25.68||||25.68||716.52|5.14
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.91||||8.91||6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.91||||8.91|4.46|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.91||||8.91|6.42|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.91||||8.91|4.46|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.91||||8.91|4.46|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.91||||8.91|6.77|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.91||||8.91|3.56|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.91||||8.91||6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.91||||8.91|4.46|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|Self-pay|Self-pay|8.91||||8.91|1.78|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.91||||8.91|3.47|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.91||||8.91||6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.91||||8.91||6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.91||||8.91||6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.91||||8.91|6.15|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.91||||8.91|0|6.77|1.78
6219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 64.8 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.91||||8.91||6.77|1.78
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|821.52||||821.52||624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|821.52||||821.52|59.36|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|821.52||||821.52|591.49|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|821.52||||821.52|410.76|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|821.52||||821.52|410.76|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|821.52||||821.52|624.36|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|821.52||||821.52|328.61|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|821.52||||821.52||624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|821.52||||821.52|59.36|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|821.52||||821.52|164.3|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|821.52||||821.52|319.74|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|821.52||||821.52||624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|821.52||||821.52||624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|821.52||||821.52||624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|821.52||||821.52|566.85|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|821.52||||821.52|0|624.36|59.36
6221|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|821.52||||821.52||624.36|59.36
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|48.45||||48.45|24.23|200.64|9.69
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]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.45||||48.45|18.86|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|48.45||||48.45|18.86|200.64|9.69
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]|48.45||||48.45|0|200.64|9.69
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]|48.45||||48.45|34.88|200.64|9.69
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]|48.45||||48.45|24.23|200.64|9.69
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]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|48.45||||48.45|36.82|200.64|9.69
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]|48.45||||48.45|18.86|200.64|9.69
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]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|48.45||||48.45|33.43|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|48.45||||48.45|19.38|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.45||||48.45|33.43|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|48.45||||48.45|33.43|200.64|9.69
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]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.45||||48.45|18.86|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.45||||48.45|0|200.64|9.69
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]|48.45||||48.45|18.86|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.45||||48.45|33.43|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.45||||48.45|18.86|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|48.45||||48.45|9.69|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|48.45||||48.45|33.43|200.64|9.69
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]|48.45||||48.45|18.86|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|48.45||||48.45|33.43|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.45||||48.45|0|200.64|9.69
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]|48.45||||48.45|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|48.45||||48.45|24.23|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|190.08|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|264||||264|200.64|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|264||||264|105.6|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|Self-pay|Self-pay|264||||264|52.8|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|TML [1980]|TML [198000]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|102.75|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264|132|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|264||||264|182.16|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264|0|200.64|9.69
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|264||||264|132|200.64|9.69
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|1188||||1188||902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1188||||1188|594|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1188||||1188|855.36|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1188||||1188|594|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1188||||1188|594|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1188||||1188|902.88|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1188||||1188|475.2|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1188||||1188||902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1188||||1188|594|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|Self-pay|Self-pay|1188||||1188|237.6|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|TML [1980]|TML [198000]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1188||||1188|462.37|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1188||||1188||902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|1188||||1188||902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1188||||1188||902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|1188||||1188|819.72|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1188||||1188|0|902.88|237.6
6246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 2.5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1188||||1188||902.88|237.6
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|18.35||||18.35||13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.35||||18.35|0.73|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.35||||18.35|13.21|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.35||||18.35|9.18|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.35||||18.35|9.18|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.35||||18.35|13.95|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|18.35||||18.35|7.34|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.35||||18.35||13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.35||||18.35|0.73|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|18.35||||18.35|3.67|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.35||||18.35|7.14|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.35||||18.35||13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|18.35||||18.35||13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.35||||18.35||13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|18.35||||18.35|12.66|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.35||||18.35|0|13.95|0.73
6256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|18.35||||18.35||13.95|0.73
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.49||||7.49||5.69|1.5
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]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.49||||7.49|2.92|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.49||||7.49|3.75|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.49||||7.49|2.92|5.69|1.5
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]|7.49||||7.49|0|5.69|1.5
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]|7.49||||7.49|5.39|5.69|1.5
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]|7.49||||7.49|3.75|5.69|1.5
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]|7.49||||7.49|3.75|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.49||||7.49|5.69|5.69|1.5
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]|7.49||||7.49|2.92|5.69|1.5
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]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.49||||7.49|5.17|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.49||||7.49|3|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.49||||7.49||5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.49||||7.49|5.17|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.49||||7.49|3.75|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.49||||7.49|5.17|5.69|1.5
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]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.49||||7.49|2.92|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.49||||7.49|0|5.69|1.5
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]|7.49||||7.49|2.92|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.49||||7.49|5.17|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.49||||7.49|2.92|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.49||||7.49|1.5|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.49||||7.49|5.17|5.69|1.5
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]|7.49||||7.49|2.92|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.49||||7.49||5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.49||||7.49||5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.49||||7.49||5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.49||||7.49|5.17|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.49||||7.49|0|5.69|1.5
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]|7.49||||7.49|0|5.69|1.5
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.49||||7.49||5.69|1.5
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|1001.69||||1001.69||761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AMBETTER [2930]|AMBETTER [293000]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1001.69||||1001.69|500.85|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1001.69||||1001.69|389.86|761.28|200.34
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]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1001.69||||1001.69|721.22|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1001.69||||1001.69|500.85|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1001.69||||1001.69|500.85|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1001.69||||1001.69|761.28|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1001.69||||1001.69|691.17|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA PPO [126025]|1001.69||||1001.69|400.68|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1001.69||||1001.69||761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1001.69||||1001.69|691.17|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1001.69||||1001.69|500.85|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1001.69||||1001.69|691.17|761.28|200.34
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]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1001.69||||1001.69|0|761.28|200.34
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]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1001.69||||1001.69|691.17|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|Self-pay|Self-pay|1001.69||||1001.69|200.34|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|TML [1980]|TML [198000]|1001.69||||1001.69|691.17|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1001.69||||1001.69|389.86|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1001.69||||1001.69||761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UNICARE [2040]|UNICARE [204000]|1001.69||||1001.69||761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1001.69||||1001.69||761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|WEB TPA [2115]|WEB TPA [211500]|1001.69||||1001.69|691.17|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1001.69||||1001.69|0|761.28|200.34
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]|1001.69||||1001.69|0|761.28|200.34
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TML WC [212537]|1001.69||||1001.69||761.28|200.34
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AARP [1000]|AARP [100000]|145.2||||145.2||110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AETNA [1015]|AETNA [101529]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AMBETTER [2930]|AMBETTER [293000]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.2||||145.2|72.6|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.2||||145.2|104.54|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.2||||145.2|72.6|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.2||||145.2|72.6|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.2||||145.2|110.35|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|CIGNA [1260]|CIGNA PPO [126025]|145.2||||145.2|58.08|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.2||||145.2||110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|GROUP PENSION ADMIN [1450]|GPA [145000]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.2||||145.2|72.6|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|PHCS [1780]|PHCS MULTIPLAN [178000]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|Self-pay|Self-pay|145.2||||145.2|29.04|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|TML [1980]|TML [198000]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.2||||145.2|56.51|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.2||||145.2||110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|UNICARE [2040]|UNICARE [204000]|145.2||||145.2||110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.2||||145.2||110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|WEB TPA [2115]|WEB TPA [211500]|145.2||||145.2|100.19|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.2||||145.2|0|110.35|29.04
6393|ERX|0250 - PHARMACY-GENERAL|POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION|500,000 Units|WORKER'S COMP [2125]|TML WC [212537]|145.2||||145.2||110.35|29.04
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|139.26||||139.26||105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|139.26||||139.26|69.63|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.26||||139.26|100.27|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.26||||139.26|69.63|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.26||||139.26|69.63|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|139.26||||139.26|105.84|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|139.26||||139.26|55.7|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|139.26||||139.26||105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|139.26||||139.26|69.63|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|139.26||||139.26|27.85|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.26||||139.26|54.2|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.26||||139.26||105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|139.26||||139.26||105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.26||||139.26||105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|139.26||||139.26|96.09|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.26||||139.26|0|105.84|27.85
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|139.26||||139.26||105.84|27.85
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|26.4||||26.4|13.2|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.4||||26.4|10.27|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.4||||26.4|0.21|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.4||||26.4|10.27|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
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]|26.4||||26.4|19.01|20.06|0.21
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]|26.4||||26.4|13.2|20.06|0.21
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]|26.4||||26.4|13.2|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.4||||26.4|20.06|20.06|0.21
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]|26.4||||26.4|10.27|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.4||||26.4|18.22|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|26.4||||26.4|10.56|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.4||||26.4|13.2|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.4||||26.4|18.22|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.4||||26.4|0.21|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.4||||26.4|18.22|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.4||||26.4|0|20.06|0.21
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]|26.4||||26.4|10.27|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.4||||26.4|0|20.06|0.21
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]|26.4||||26.4|10.27|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.4||||26.4|18.22|20.06|0.21
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]|26.4||||26.4|10.27|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|26.4||||26.4|5.28|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|26.4||||26.4|18.22|20.06|0.21
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]|26.4||||26.4|10.27|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.4||||26.4|13.2|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|26.4||||26.4|13.2|20.06|0.21
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]|26.4||||26.4|13.2|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|26.4||||26.4|18.22|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
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]|26.4||||26.4|0|20.06|0.21
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|26.4||||26.4|13.2|20.06|0.21
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AARP [1000]|AARP [100000]|95.19||||95.19||72.34|19.04
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]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AETNA [1015]|AETNA [101529]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95.19||||95.19|37.05|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|95.19||||95.19|47.6|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|95.19||||95.19|37.05|72.34|19.04
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]|95.19||||95.19|0|72.34|19.04
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]|95.19||||95.19|68.54|72.34|19.04
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]|95.19||||95.19|47.6|72.34|19.04
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]|95.19||||95.19|47.6|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|95.19||||95.19|72.34|72.34|19.04
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]|95.19||||95.19|37.05|72.34|19.04
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]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|95.19||||95.19|65.68|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|95.19||||95.19|38.08|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|95.19||||95.19||72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|95.19||||95.19|65.68|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|95.19||||95.19|47.6|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|95.19||||95.19|65.68|72.34|19.04
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]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95.19||||95.19|37.05|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95.19||||95.19|0|72.34|19.04
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]|95.19||||95.19|37.05|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|95.19||||95.19|65.68|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95.19||||95.19|37.05|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|Self-pay|Self-pay|95.19||||95.19|19.04|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|TML [1980]|TML [198000]|95.19||||95.19|65.68|72.34|19.04
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]|95.19||||95.19|37.05|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95.19||||95.19||72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|95.19||||95.19||72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95.19||||95.19||72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|95.19||||95.19|65.68|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95.19||||95.19|0|72.34|19.04
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]|95.19||||95.19|0|72.34|19.04
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|95.19||||95.19||72.34|19.04
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|7.09||||7.09||5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.09||||7.09|3.55|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.09||||7.09|2.76|5.39|1.42
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]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.09||||7.09|5.1|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.09||||7.09|3.55|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.09||||7.09|3.55|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.09||||7.09|5.39|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.09||||7.09|4.89|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|7.09||||7.09|2.84|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.09||||7.09||5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.09||||7.09|4.89|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.09||||7.09|3.55|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.09||||7.09|4.89|5.39|1.42
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]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.09||||7.09|0|5.39|1.42
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]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.09||||7.09|4.89|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|7.09||||7.09|1.42|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|7.09||||7.09|4.89|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.09||||7.09|2.76|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.09||||7.09||5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|7.09||||7.09||5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.09||||7.09||5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|7.09||||7.09|4.89|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.09||||7.09|0|5.39|1.42
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]|7.09||||7.09|0|5.39|1.42
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|7.09||||7.09||5.39|1.42
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|2117.28||||2117.28||1609.13|423.46
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]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2117.28||||2117.28|824.05|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2117.28||||2117.28|1058.64|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2117.28||||2117.28|824.05|1609.13|423.46
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]|2117.28||||2117.28|0|1609.13|423.46
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]|2117.28||||2117.28|1524.44|1609.13|423.46
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]|2117.28||||2117.28|1058.64|1609.13|423.46
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]|2117.28||||2117.28|1058.64|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2117.28||||2117.28|1609.13|1609.13|423.46
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]|2117.28||||2117.28|824.05|1609.13|423.46
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]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2117.28||||2117.28|1460.92|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2117.28||||2117.28|846.91|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2117.28||||2117.28||1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2117.28||||2117.28|1460.92|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2117.28||||2117.28|1058.64|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2117.28||||2117.28|1460.92|1609.13|423.46
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]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2117.28||||2117.28|824.05|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2117.28||||2117.28|0|1609.13|423.46
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]|2117.28||||2117.28|824.05|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2117.28||||2117.28|1460.92|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2117.28||||2117.28|824.05|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|2117.28||||2117.28|423.46|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|TML [1980]|TML [198000]|2117.28||||2117.28|1460.92|1609.13|423.46
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]|2117.28||||2117.28|824.05|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2117.28||||2117.28||1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|2117.28||||2117.28||1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2117.28||||2117.28||1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|2117.28||||2117.28|1460.92|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2117.28||||2117.28|0|1609.13|423.46
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]|2117.28||||2117.28|0|1609.13|423.46
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2117.28||||2117.28||1609.13|423.46
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AARP [1000]|AARP [100000]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4092||||4092|0.01|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4092||||4092|2946.24|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4092||||4092|3109.92|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|4092||||4092|1636.8|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4092||||4092|0.01|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|Self-pay|Self-pay|4092||||4092|818.4|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|TML [1980]|TML [198000]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4092||||4092|1592.61|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4092||||4092|2046|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|4092||||4092|2823.48|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4092||||4092|0|3109.92|0.01
6492|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG/5 ML ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|4092||||4092|2046|3109.92|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.67||||2.67|1.34|2.03|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]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.67||||2.67|1.04|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.67||||2.67|0.01|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.67||||2.67|1.04|2.03|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]|2.67||||2.67|0|2.03|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]|2.67||||2.67|1.92|2.03|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]|2.67||||2.67|1.34|2.03|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]|2.67||||2.67|1.34|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.67||||2.67|2.03|2.03|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]|2.67||||2.67|1.04|2.03|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]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.67||||2.67|1.84|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.67||||2.67|1.07|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.67||||2.67|1.34|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.67||||2.67|1.84|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.67||||2.67|0.01|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.67||||2.67|1.84|2.03|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]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.67||||2.67|1.04|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.67||||2.67|0|2.03|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]|2.67||||2.67|1.04|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.67||||2.67|1.84|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.67||||2.67|1.04|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.67||||2.67|0.53|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.67||||2.67|1.84|2.03|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]|2.67||||2.67|1.04|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.67||||2.67|1.34|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.67||||2.67|1.34|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.67||||2.67|1.34|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.67||||2.67|1.84|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.67||||2.67|0|2.03|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]|2.67||||2.67|0|2.03|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.67||||2.67|1.34|2.03|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.01||||3.01|1.51|2.29|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]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.01||||3.01|1.17|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.01||||3.01|0.01|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.01||||3.01|1.17|2.29|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]|3.01||||3.01|0|2.29|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]|3.01||||3.01|2.17|2.29|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]|3.01||||3.01|1.51|2.29|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]|3.01||||3.01|1.51|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.01||||3.01|2.29|2.29|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]|3.01||||3.01|1.17|2.29|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]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.01||||3.01|2.08|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.01||||3.01|1.2|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.01||||3.01|1.51|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.01||||3.01|2.08|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.01||||3.01|0.01|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.01||||3.01|2.08|2.29|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]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.01||||3.01|1.17|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.01||||3.01|0|2.29|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]|3.01||||3.01|1.17|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.01||||3.01|2.08|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.01||||3.01|1.17|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|3.01||||3.01|0.6|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.01||||3.01|2.08|2.29|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]|3.01||||3.01|1.17|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.01||||3.01|1.51|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.01||||3.01|1.51|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.01||||3.01|1.51|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.01||||3.01|2.08|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.01||||3.01|0|2.29|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]|3.01||||3.01|0|2.29|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.01||||3.01|1.51|2.29|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.63||||2.63|1.32|2|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]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.63||||2.63|1.02|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.63||||2.63|0.01|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.63||||2.63|1.02|2|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]|2.63||||2.63|0|2|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]|2.63||||2.63|1.89|2|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]|2.63||||2.63|1.32|2|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]|2.63||||2.63|1.32|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.63||||2.63|2|2|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]|2.63||||2.63|1.02|2|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]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.63||||2.63|1.81|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.63||||2.63|1.05|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.63||||2.63|1.32|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.63||||2.63|1.81|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.63||||2.63|0.01|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.63||||2.63|1.81|2|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]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.63||||2.63|1.02|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.63||||2.63|0|2|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]|2.63||||2.63|1.02|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.63||||2.63|1.81|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.63||||2.63|1.02|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.63||||2.63|0.53|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.63||||2.63|1.81|2|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]|2.63||||2.63|1.02|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.63||||2.63|1.32|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.63||||2.63|1.32|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.63||||2.63|1.32|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.63||||2.63|1.81|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.63||||2.63|0|2|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]|2.63||||2.63|0|2|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.63||||2.63|1.32|2|0.01
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|26.6||||26.6||20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.6||||26.6|13.3|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.6||||26.6|19.15|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.6||||26.6|13.3|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.6||||26.6|13.3|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.6||||26.6|20.22|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|26.6||||26.6|10.64|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.6||||26.6||20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.6||||26.6|13.3|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|Self-pay|Self-pay|26.6||||26.6|5.32|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.6||||26.6|10.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.6||||26.6||20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|26.6||||26.6||20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.6||||26.6||20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|26.6||||26.6|18.35|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.6||||26.6|0|20.22|5.32
6561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROBENECID 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|26.6||||26.6||20.22|5.32
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|1145.9||||1145.9||870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1145.9||||1145.9|106.28|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1145.9||||1145.9|825.05|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1145.9||||1145.9|572.95|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1145.9||||1145.9|572.95|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1145.9||||1145.9|870.88|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1145.9||||1145.9|458.36|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1145.9||||1145.9||870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1145.9||||1145.9|106.28|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|1145.9||||1145.9|229.18|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1145.9||||1145.9|445.98|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1145.9||||1145.9||870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|1145.9||||1145.9||870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1145.9||||1145.9||870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|1145.9||||1145.9|790.67|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1145.9||||1145.9|0|870.88|106.28
6562|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 100 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1145.9||||1145.9||870.88|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|3960||||3960||3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3960||||3960|106.28|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3960||||3960|2851.2|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3960||||3960|1980|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3960||||3960|1980|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3960||||3960|3009.6|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|3960||||3960|1584|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3960||||3960||3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3960||||3960|106.28|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|3960||||3960|792|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3960||||3960|1541.23|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3960||||3960||3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|3960||||3960||3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3960||||3960||3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|3960||||3960|2732.4|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3960||||3960|0|3009.6|106.28
6563|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCAINAMIDE 500 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|3960||||3960||3009.6|106.28
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]|60.72||||60.72|30.36|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|60.72||||60.72|6.59|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|43.72|46.15|6.59
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]|60.72||||60.72|30.36|46.15|6.59
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]|60.72||||60.72|30.36|46.15|6.59
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 TRADITIONAL OF TEXAS [115503]|60.72||||60.72|46.15|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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 - GREAT WEST [126009]|60.72||||60.72|41.9|46.15|6.59
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 PPO [126025]|60.72||||60.72|24.29|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|60.72||||60.72|30.36|46.15|6.59
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]|60.72||||60.72|41.9|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|60.72||||60.72|6.59|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|60.72||||60.72|41.9|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|41.9|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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|60.72||||60.72|12.14|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|60.72||||60.72|41.9|46.15|6.59
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]|60.72||||60.72|23.63|46.15|6.59
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]|60.72||||60.72|30.36|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|60.72||||60.72|30.36|46.15|6.59
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]|60.72||||60.72|30.36|46.15|6.59
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|60.72||||60.72|41.9|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|60.72||||60.72|0|46.15|6.59
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]|TML WC [212537]|60.72||||60.72|30.36|46.15|6.59
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.34||||6.34||4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.34||||6.34|0.39|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.34||||6.34|4.56|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.34||||6.34|3.17|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.34||||6.34|3.17|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.34||||6.34|4.82|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6.34||||6.34|2.54|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.34||||6.34||4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.34||||6.34|0.39|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|Self-pay|Self-pay|6.34||||6.34|1.27|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.34||||6.34|2.47|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.34||||6.34||4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6.34||||6.34||4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.34||||6.34||4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6.34||||6.34|4.37|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.34||||6.34|0|4.82|0.39
6582|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6.34||||6.34||4.82|0.39
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AARP [1000]|AARP [100000]|530.71||||530.71||403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AETNA [1015]|AETNA [101529]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AMBETTER [2930]|AMBETTER [293000]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|530.71||||530.71|265.36|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|530.71||||530.71|382.11|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|530.71||||530.71|265.36|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|530.71||||530.71|265.36|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|530.71||||530.71|403.34|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|CIGNA [1260]|CIGNA PPO [126025]|530.71||||530.71|212.28|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|530.71||||530.71||403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|530.71||||530.71|265.36|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|Self-pay|Self-pay|530.71||||530.71|106.14|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|TML [1980]|TML [198000]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|530.71||||530.71|206.55|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|530.71||||530.71||403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|UNICARE [2040]|UNICARE [204000]|530.71||||530.71||403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|530.71||||530.71||403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|WEB TPA [2115]|WEB TPA [211500]|530.71||||530.71|366.19|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|530.71||||530.71|0|403.34|106.14
6620|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 6.25 MG/5 ML SYRUP REPACK|473 mL|WORKER'S COMP [2125]|TML WC [212537]|530.71||||530.71||403.34|106.14
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.02||||5.02||3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.02||||5.02|2.51|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.02||||5.02|1.95|3.82|1
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]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.02||||5.02|3.61|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.02||||5.02|2.51|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.02||||5.02|2.51|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.02||||5.02|3.82|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.02||||5.02|3.46|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.02||||5.02|2.01|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.02||||5.02||3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.02||||5.02|3.46|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.02||||5.02|2.51|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.02||||5.02|3.46|3.82|1
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]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.02||||5.02|3.46|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|5.02||||5.02|1|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.02||||5.02|3.46|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.02||||5.02|1.95|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.02||||5.02||3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.02||||5.02||3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.02||||5.02||3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.02||||5.02|3.46|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.02||||5.02|0|3.82|1
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]|5.02||||5.02|0|3.82|1
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.02||||5.02||3.82|1
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.28||||0.28||0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.11|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.28||||0.28|0.14|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.28||||0.28|0.11|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
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]|0.28||||0.28|0.2|0.21|0.06
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]|0.28||||0.28|0.14|0.21|0.06
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]|0.28||||0.28|0.14|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.28||||0.28|0.21|0.21|0.06
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]|0.28||||0.28|0.11|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.28||||0.28|0.19|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.28||||0.28|0.11|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.28||||0.28||0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.28||||0.28|0.14|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.28||||0.28|0.19|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0|0.21|0.06
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]|0.28||||0.28|0.11|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0|0.21|0.06
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]|0.28||||0.28|0.11|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.21|0.06
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]|0.28||||0.28|0.11|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.28||||0.28|0.06|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.28||||0.28|0.19|0.21|0.06
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]|0.28||||0.28|0.11|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.28||||0.28||0.21|0.06
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]|0.28||||0.28||0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.28||||0.28|0.19|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
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]|0.28||||0.28|0|0.21|0.06
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.28||||0.28||0.21|0.06
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.17||||7.17||5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.17||||7.17|3.59|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.17||||7.17|5.16|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.17||||7.17|3.59|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.17||||7.17|3.59|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.17||||7.17|5.45|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.17||||7.17|2.87|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.17||||7.17||5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.17||||7.17|3.59|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|Self-pay|Self-pay|7.17||||7.17|1.43|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.17||||7.17|2.79|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.17||||7.17||5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.17||||7.17||5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.17||||7.17||5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.17||||7.17|4.95|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.17||||7.17|0|5.45|1.43
6658|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.17||||7.17||5.45|1.43
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|162.23||||162.23|81.12|123.29|1.46
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]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162.23||||162.23|63.14|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|162.23||||162.23|1.46|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|162.23||||162.23|63.14|123.29|1.46
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]|162.23||||162.23|0|123.29|1.46
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]|162.23||||162.23|116.81|123.29|1.46
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]|162.23||||162.23|81.12|123.29|1.46
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]|162.23||||162.23|81.12|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|162.23||||162.23|123.29|123.29|1.46
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]|162.23||||162.23|63.14|123.29|1.46
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]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|162.23||||162.23|111.94|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|162.23||||162.23|64.89|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|162.23||||162.23|81.12|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|162.23||||162.23|111.94|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|162.23||||162.23|1.46|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|162.23||||162.23|111.94|123.29|1.46
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]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162.23||||162.23|63.14|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162.23||||162.23|0|123.29|1.46
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]|162.23||||162.23|63.14|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|162.23||||162.23|111.94|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162.23||||162.23|63.14|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|162.23||||162.23|32.45|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|162.23||||162.23|111.94|123.29|1.46
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]|162.23||||162.23|63.14|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162.23||||162.23|81.12|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|162.23||||162.23|81.12|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162.23||||162.23|81.12|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|162.23||||162.23|111.94|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162.23||||162.23|0|123.29|1.46
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]|162.23||||162.23|0|123.29|1.46
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|162.23||||162.23|81.12|123.29|1.46
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.11||||3.11||2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.11||||3.11|1.21|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.11||||3.11|1.56|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.11||||3.11|1.21|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
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]|3.11||||3.11|2.24|2.36|0.62
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]|3.11||||3.11|1.56|2.36|0.62
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]|3.11||||3.11|1.56|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.11||||3.11|2.36|2.36|0.62
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]|3.11||||3.11|1.21|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.11||||3.11|2.15|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.11||||3.11|1.24|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.11||||3.11||2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.11||||3.11|2.15|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.11||||3.11|1.56|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.11||||3.11|2.15|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.11||||3.11|1.21|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.11||||3.11|0|2.36|0.62
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]|3.11||||3.11|1.21|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.11||||3.11|2.15|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.11||||3.11|1.21|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|Self-pay|Self-pay|3.11||||3.11|0.62|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.11||||3.11|2.15|2.36|0.62
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]|3.11||||3.11|1.21|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.11||||3.11||2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.11||||3.11||2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.11||||3.11||2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.11||||3.11|2.15|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.11||||3.11|0|2.36|0.62
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]|3.11||||3.11|0|2.36|0.62
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.11||||3.11||2.36|0.62
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.63||||0.63||0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.63||||0.63|0.32|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.63||||0.63|0.45|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.63||||0.63|0.32|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.63||||0.63|0.32|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.63||||0.63|0.48|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.63||||0.63||0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.63||||0.63|0.32|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|Self-pay|Self-pay|0.63||||0.63|0.13|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.63||||0.63|0.25|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.63||||0.63||0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.63||||0.63||0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.63||||0.63||0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.63||||0.63|0.43|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.63||||0.63|0|0.48|0.13
681|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.63||||0.63||0.48|0.13
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|15.41||||15.41||11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMBETTER [2930]|AMBETTER [293000]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|15.41||||15.41|7.71|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|15.41||||15.41|6|11.71|3.08
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]|15.41||||15.41|0|11.71|3.08
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]|15.41||||15.41|11.1|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.41||||15.41|7.71|11.71|3.08
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]|15.41||||15.41|7.71|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|15.41||||15.41|11.71|11.71|3.08
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]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA - GREAT WEST [126009]|15.41||||15.41|10.63|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA PPO [126025]|15.41||||15.41|6.16|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|15.41||||15.41||11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|15.41||||15.41|10.63|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|15.41||||15.41|7.71|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|15.41||||15.41|10.63|11.71|3.08
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]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.41||||15.41|0|11.71|3.08
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]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|15.41||||15.41|10.63|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|15.41||||15.41|3.08|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|TML [1980]|TML [198000]|15.41||||15.41|10.63|11.71|3.08
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]|15.41||||15.41|6|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.41||||15.41||11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNICARE [2040]|UNICARE [204000]|15.41||||15.41||11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.41||||15.41||11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WEB TPA [2115]|WEB TPA [211500]|15.41||||15.41|10.63|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.41||||15.41|0|11.71|3.08
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]|15.41||||15.41|0|11.71|3.08
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TML WC [212537]|15.41||||15.41||11.71|3.08
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|2327.96||||2327.96||1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2327.96||||2327.96|1163.98|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2327.96||||2327.96|906.04|1769.25|465.59
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]|2327.96||||2327.96|0|1769.25|465.59
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]|2327.96||||2327.96|1676.13|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2327.96||||2327.96|1163.98|1769.25|465.59
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]|2327.96||||2327.96|1163.98|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2327.96||||2327.96|1769.25|1769.25|465.59
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]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2327.96||||2327.96|1606.29|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2327.96||||2327.96|931.18|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2327.96||||2327.96||1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2327.96||||2327.96|1606.29|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2327.96||||2327.96|1163.98|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2327.96||||2327.96|1606.29|1769.25|465.59
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]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2327.96||||2327.96|0|1769.25|465.59
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]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2327.96||||2327.96|1606.29|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|2327.96||||2327.96|465.59|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|2327.96||||2327.96|1606.29|1769.25|465.59
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]|2327.96||||2327.96|906.04|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2327.96||||2327.96||1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|2327.96||||2327.96||1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2327.96||||2327.96||1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|2327.96||||2327.96|1606.29|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2327.96||||2327.96|0|1769.25|465.59
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]|2327.96||||2327.96|0|1769.25|465.59
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2327.96||||2327.96||1769.25|465.59
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|14.66||||14.66||11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.66||||14.66|7.33|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.66||||14.66|10.56|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.66||||14.66|7.33|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.66||||14.66|7.33|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.66||||14.66|11.14|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|14.66||||14.66|5.86|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.66||||14.66||11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.66||||14.66|7.33|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|Self-pay|Self-pay|14.66||||14.66|2.93|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.66||||14.66|5.71|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.66||||14.66||11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|14.66||||14.66||11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.66||||14.66||11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|14.66||||14.66|10.12|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.66||||14.66|0|11.14|2.93
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]|14.66||||14.66|0|11.14|2.93
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|14.66||||14.66||11.14|2.93
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]|7.19||||7.19||5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.19||||7.19|3.6|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|5.18|5.46|1.44
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]|7.19||||7.19|3.6|5.46|1.44
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]|7.19||||7.19|3.6|5.46|1.44
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 TRADITIONAL OF TEXAS [115503]|7.19||||7.19|5.46|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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 - GREAT WEST [126009]|7.19||||7.19|4.96|5.46|1.44
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 PPO [126025]|7.19||||7.19|2.88|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.19||||7.19||5.46|1.44
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]|7.19||||7.19|4.96|5.46|1.44
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.19||||7.19|3.6|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.19||||7.19|4.96|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19|4.96|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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|7.19||||7.19|1.44|5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|7.19||||7.19|4.96|5.46|1.44
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]|7.19||||7.19|2.8|5.46|1.44
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]|7.19||||7.19||5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|7.19||||7.19||5.46|1.44
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]|7.19||||7.19||5.46|1.44
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|7.19||||7.19|4.96|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|7.19||||7.19|0|5.46|1.44
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]|TML WC [212537]|7.19||||7.19||5.46|1.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|302.21||||302.21||229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|302.21||||302.21|151.11|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|302.21||||302.21|117.62|229.68|60.44
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]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|302.21||||302.21|217.59|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|302.21||||302.21|151.11|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|302.21||||302.21|151.11|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|302.21||||302.21|229.68|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|302.21||||302.21|208.52|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|302.21||||302.21|120.88|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|302.21||||302.21||229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|302.21||||302.21|208.52|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|302.21||||302.21|151.11|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|302.21||||302.21|208.52|229.68|60.44
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]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|302.21||||302.21|0|229.68|60.44
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]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|302.21||||302.21|208.52|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|Self-pay|Self-pay|302.21||||302.21|60.44|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|302.21||||302.21|208.52|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|302.21||||302.21|117.62|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|302.21||||302.21||229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|302.21||||302.21||229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|302.21||||302.21||229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|302.21||||302.21|208.52|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|302.21||||302.21|0|229.68|60.44
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]|302.21||||302.21|0|229.68|60.44
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|302.21||||302.21||229.68|60.44
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|90.46||||90.46||68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMBETTER [2930]|AMBETTER [293000]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|90.46||||90.46|45.23|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.46||||90.46|65.13|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.46||||90.46|45.23|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.46||||90.46|45.23|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|90.46||||90.46|68.75|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|90.46||||90.46|36.18|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|90.46||||90.46||68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|90.46||||90.46|45.23|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|90.46||||90.46|18.09|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TML [1980]|TML [198000]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.46||||90.46|35.21|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.46||||90.46||68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNICARE [2040]|UNICARE [204000]|90.46||||90.46||68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.46||||90.46||68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WEB TPA [2115]|WEB TPA [211500]|90.46||||90.46|62.42|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.46||||90.46|0|68.75|18.09
70434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|90.46||||90.46||68.75|18.09
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|81.65||||81.65||62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.65||||81.65|40.83|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.65||||81.65|31.78|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.65||||81.65|58.79|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.65||||81.65|40.83|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.65||||81.65|40.83|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.65||||81.65|62.05|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.65||||81.65|56.34|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|81.65||||81.65|32.66|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.65||||81.65||62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|81.65||||81.65|56.34|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.65||||81.65|40.83|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.65||||81.65|56.34|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.65||||81.65|0|62.05|16.33
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]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|81.65||||81.65|56.34|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|Self-pay|Self-pay|81.65||||81.65|16.33|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|81.65||||81.65|56.34|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.65||||81.65|31.78|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.65||||81.65||62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|81.65||||81.65||62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.65||||81.65||62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|81.65||||81.65|56.34|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.65||||81.65|0|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|81.65||||81.65||62.05|16.33
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AARP [1000]|AARP [100000]|145.31||||145.31||110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AETNA [1015]|AETNA [101529]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMBETTER [2930]|AMBETTER [293000]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|145.31||||145.31|72.66|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|145.31||||145.31|56.55|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|104.62|110.44|29.06
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]|145.31||||145.31|72.66|110.44|29.06
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]|145.31||||145.31|72.66|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|145.31||||145.31|110.44|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|145.31||||145.31|100.26|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA [1260]|CIGNA PPO [126025]|145.31||||145.31|58.12|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|145.31||||145.31||110.44|29.06
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]|145.31||||145.31|100.26|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|145.31||||145.31|72.66|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|145.31||||145.31|100.26|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|PHCS [1780]|PHCS MULTIPLAN [178000]|145.31||||145.31|100.26|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|Self-pay|Self-pay|145.31||||145.31|29.06|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|TML [1980]|TML [198000]|145.31||||145.31|100.26|110.44|29.06
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]|145.31||||145.31|56.55|110.44|29.06
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]|145.31||||145.31||110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNICARE [2040]|UNICARE [204000]|145.31||||145.31||110.44|29.06
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]|145.31||||145.31||110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WEB TPA [2115]|WEB TPA [211500]|145.31||||145.31|100.26|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
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]|145.31||||145.31|0|110.44|29.06
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WORKER'S COMP [2125]|TML WC [212537]|145.31||||145.31||110.44|29.06
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AARP [1000]|AARP [100000]|1947.85||||1947.85||1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AMBETTER [2930]|AMBETTER [293000]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1947.85||||1947.85|973.93|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1947.85||||1947.85|1402.45|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1947.85||||1947.85|973.93|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1947.85||||1947.85|973.93|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1947.85||||1947.85|1480.37|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|1947.85||||1947.85|779.14|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1947.85||||1947.85||1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1947.85||||1947.85|973.93|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|Self-pay|Self-pay|1947.85||||1947.85|389.57|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|TML [1980]|TML [198000]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1947.85||||1947.85|758.1|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1947.85||||1947.85||1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UNICARE [2040]|UNICARE [204000]|1947.85||||1947.85||1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1947.85||||1947.85||1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|WEB TPA [2115]|WEB TPA [211500]|1947.85||||1947.85|1344.02|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1947.85||||1947.85|0|1480.37|389.57
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]|1947.85||||1947.85|0|1480.37|389.57
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|1947.85||||1947.85||1480.37|389.57
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AARP [1000]|AARP [100000]|959||||959||728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AMBETTER [2930]|AMBETTER [293000]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|959||||959|479.5|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|959||||959|690.48|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|959||||959|479.5|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|959||||959|479.5|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|959||||959|728.84|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|CIGNA [1260]|CIGNA PPO [126025]|959||||959|383.6|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|959||||959||728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|959||||959|479.5|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|Self-pay|Self-pay|959||||959|191.8|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|TML [1980]|TML [198000]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|959||||959|373.24|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|959||||959||728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|UNICARE [2040]|UNICARE [204000]|959||||959||728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|959||||959||728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|WEB TPA [2115]|WEB TPA [211500]|959||||959|661.71|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|959||||959|0|728.84|191.8
71000135|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL 2 1ST 30 MIN|1|WORKER'S COMP [2125]|TML WC [212537]|959||||959||728.84|191.8
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.52||||0.52||0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.52||||0.52|0.26|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.52||||0.52|0.37|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.52||||0.52|0.26|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.52||||0.52|0.26|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.52||||0.52|0.4|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.52||||0.52|0.21|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.52||||0.52||0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.52||||0.52|0.26|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|Self-pay|Self-pay|0.52||||0.52|0.1|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|TML [1980]|TML [198000]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.52||||0.52|0.2|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.52||||0.52||0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.52||||0.52||0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.52||||0.52||0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.52||||0.52|0.36|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.52||||0.52|0|0.4|0.1
7139|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SELENIUM 200 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.52||||0.52||0.4|0.1
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.3||||2.3||1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.3||||2.3|1.15|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.3||||2.3|0.9|1.75|0.46
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]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.3||||2.3|1.66|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.3||||2.3|1.15|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.3||||2.3|1.15|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.3||||2.3|1.75|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.3||||2.3|1.59|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.3||||2.3|0.92|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.3||||2.3||1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.3||||2.3|1.59|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.3||||2.3|1.15|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.3||||2.3|1.59|1.75|0.46
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]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.3||||2.3|0|1.75|0.46
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]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.3||||2.3|1.59|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.3||||2.3|0.46|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.3||||2.3|1.59|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.3||||2.3|0.9|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.3||||2.3||1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.3||||2.3||1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.3||||2.3||1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.3||||2.3|1.59|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.3||||2.3|0|1.75|0.46
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]|2.3||||2.3|0|1.75|0.46
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.3||||2.3||1.75|0.46
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AARP [1000]|AARP [100000]|781.44||||781.44||593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AETNA [1015]|AETNA [101529]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AMBETTER [2930]|AMBETTER [293000]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|781.44||||781.44|390.72|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|781.44||||781.44|562.64|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|781.44||||781.44|390.72|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|781.44||||781.44|390.72|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|781.44||||781.44|593.89|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|CIGNA [1260]|CIGNA PPO [126025]|781.44||||781.44|312.58|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|781.44||||781.44||593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|GROUP PENSION ADMIN [1450]|GPA [145000]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|781.44||||781.44|390.72|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|PHCS [1780]|PHCS MULTIPLAN [178000]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|Self-pay|Self-pay|781.44||||781.44|156.29|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|TML [1980]|TML [198000]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|781.44||||781.44|304.14|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|781.44||||781.44||593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|UNICARE [2040]|UNICARE [204000]|781.44||||781.44||593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|781.44||||781.44||593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|WEB TPA [2115]|WEB TPA [211500]|781.44||||781.44|539.19|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|781.44||||781.44|0|593.89|156.29
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|400 g|WORKER'S COMP [2125]|TML WC [212537]|781.44||||781.44||593.89|156.29
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AARP [1000]|AARP [100000]|181.07||||181.07||137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AETNA [1015]|AETNA [101529]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AMBETTER [2930]|AMBETTER [293000]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.07||||181.07|90.54|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.07||||181.07|130.37|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.07||||181.07|90.54|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.07||||181.07|90.54|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.07||||181.07|137.61|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|CIGNA [1260]|CIGNA PPO [126025]|181.07||||181.07|72.43|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.07||||181.07||137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.07||||181.07|90.54|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|Self-pay|Self-pay|181.07||||181.07|36.21|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|TML [1980]|TML [198000]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.07||||181.07|70.47|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.07||||181.07||137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|UNICARE [2040]|UNICARE [204000]|181.07||||181.07||137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.07||||181.07||137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|WEB TPA [2115]|WEB TPA [211500]|181.07||||181.07|124.94|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.07||||181.07|0|137.61|36.21
7242|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SIMPLE SYRUP|473 mL|WORKER'S COMP [2125]|TML WC [212537]|181.07||||181.07||137.61|36.21
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AARP [1000]|AARP [100000]|137.55||||137.55|68.78|104.54|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]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMBETTER [2930]|AMBETTER [293000]|137.55||||137.55|0|104.54|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]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|137.55||||137.55|0.1|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|0|104.54|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]|137.55||||137.55|99.04|104.54|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]|137.55||||137.55|68.78|104.54|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]|137.55||||137.55|68.78|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|137.55||||137.55|104.54|104.54|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]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|137.55||||137.55|94.91|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA PPO [126025]|137.55||||137.55|55.02|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|137.55||||137.55|68.78|104.54|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]|137.55||||137.55|94.91|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|137.55||||137.55|0.1|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|137.55||||137.55|94.91|104.54|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]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|137.55||||137.55|0|104.54|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]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|0|104.54|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]|137.55||||137.55|0|104.54|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]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|94.91|104.54|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]|137.55||||137.55|53.53|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|Self-pay|Self-pay|137.55||||137.55|27.51|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|TML [1980]|TML [198000]|137.55||||137.55|94.91|104.54|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]|137.55||||137.55|53.53|104.54|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]|137.55||||137.55|68.78|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNICARE [2040]|UNICARE [204000]|137.55||||137.55|68.78|104.54|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]|137.55||||137.55|68.78|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WEB TPA [2115]|WEB TPA [211500]|137.55||||137.55|94.91|104.54|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]|137.55||||137.55|0|104.54|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]|137.55||||137.55|0|104.54|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TML WC [212537]|137.55||||137.55|68.78|104.54|0.1
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|41.72||||41.72||31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.72||||41.72|20.86|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.72||||41.72|30.04|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.72||||41.72|20.86|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.72||||41.72|20.86|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.72||||41.72|31.71|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|41.72||||41.72|16.69|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.72||||41.72||31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.72||||41.72|20.86|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|41.72||||41.72|8.34|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.72||||41.72|16.24|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.72||||41.72||31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|41.72||||41.72||31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.72||||41.72||31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|41.72||||41.72|28.79|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.72||||41.72|0|31.71|8.34
7301|ERX|0250 - PHARMACY-GENERAL|SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|41.72||||41.72||31.71|8.34
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AARP [1000]|AARP [100000]|890.25||||890.25|236|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA [1015]|AETNA [101529]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMBETTER [2930]|AMBETTER [293000]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|890.25||||890.25|72.36|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|890.25||||890.25|640.98|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|890.25||||890.25|445.13|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|890.25||||890.25|445.13|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|890.25||||890.25|676.59|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|890.25||||890.25|356.1|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|890.25||||890.25|236|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|890.25||||890.25|72.36|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|Self-pay|Self-pay|890.25||||890.25|178.05|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|TML [1980]|TML [198000]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|890.25||||890.25|346.49|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|890.25||||890.25|236|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNICARE [2040]|UNICARE [204000]|890.25||||890.25|236|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|890.25||||890.25|236|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WEB TPA [2115]|WEB TPA [211500]|890.25||||890.25|614.27|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|890.25||||890.25|0|676.59|72.36
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|890.25||||890.25|236|676.59|72.36
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|105.6||||105.6|0.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.6||||105.6|76.03|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|105.6||||105.6|80.26|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|105.6||||105.6|42.24|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|105.6||||105.6|0.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|105.6||||105.6|21.12|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.6||||105.6|41.1|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.6||||105.6|52.8|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|105.6||||105.6|72.86|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.6||||105.6|0|80.26|0.1
731|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|105.6||||105.6|52.8|80.26|0.1
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.77||||0.77||0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.77||||0.77|0.39|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.77||||0.77|0.3|0.59|0.15
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]|0.77||||0.77|0|0.59|0.15
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]|0.77||||0.77|0.55|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.77||||0.77|0.39|0.59|0.15
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]|0.77||||0.77|0.39|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.77||||0.77|0.59|0.59|0.15
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]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.77||||0.77|0.53|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.77||||0.77|0.31|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.77||||0.77||0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.77||||0.77|0.53|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.77||||0.77|0.39|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.77||||0.77|0.53|0.59|0.15
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]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.77||||0.77|0|0.59|0.15
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]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.77||||0.77|0.53|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|Self-pay|Self-pay|0.77||||0.77|0.15|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|TML [1980]|TML [198000]|0.77||||0.77|0.53|0.59|0.15
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]|0.77||||0.77|0.3|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.77||||0.77||0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.77||||0.77||0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.77||||0.77||0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.77||||0.77|0.53|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.77||||0.77|0|0.59|0.15
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]|0.77||||0.77|0|0.59|0.15
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.77||||0.77||0.59|0.15
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|3.55|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|3.55
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]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|47.52|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|3.55|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|3.55
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]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|3.55
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]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|66||||66|13.2|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|25.69|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66|33|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66|0|50.16|3.55
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]|66||||66|0|50.16|3.55
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|33|50.16|3.55
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AARP [1000]|AARP [100000]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|46.2||||46.2|1.78|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.2||||46.2|33.26|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|46.2||||46.2|35.11|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|46.2||||46.2|18.48|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|46.2||||46.2|1.78|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|Self-pay|Self-pay|46.2||||46.2|9.24|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|TML [1980]|TML [198000]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.2||||46.2|17.98|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.2||||46.2|23.1|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|46.2||||46.2|31.88|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.2||||46.2|0|35.11|1.78
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]|46.2||||46.2|0|35.11|1.78
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|46.2||||46.2|23.1|35.11|1.78
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|155.76||||155.76||118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMBETTER [2930]|AMBETTER [293000]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|155.76||||155.76|77.88|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155.76||||155.76|112.15|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155.76||||155.76|77.88|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155.76||||155.76|77.88|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|155.76||||155.76|118.38|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA PPO [126025]|155.76||||155.76|62.3|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|155.76||||155.76||118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|155.76||||155.76|77.88|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|155.76||||155.76|31.15|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|TML [1980]|TML [198000]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155.76||||155.76|60.62|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155.76||||155.76||118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UNICARE [2040]|UNICARE [204000]|155.76||||155.76||118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155.76||||155.76||118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WEB TPA [2115]|WEB TPA [211500]|155.76||||155.76|107.47|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155.76||||155.76|0|118.38|31.15
7322|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TML WC [212537]|155.76||||155.76||118.38|31.15
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AARP [1000]|AARP [100000]|10.5||||10.5||7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AETNA [1015]|AETNA [101529]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AMBETTER [2930]|AMBETTER [293000]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.5||||10.5|5.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.5||||10.5|7.56|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.5||||10.5|5.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.5||||10.5|5.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.5||||10.5|7.98|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|10.5||||10.5|4.2|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.5||||10.5||7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.5||||10.5|5.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|Self-pay|Self-pay|10.5||||10.5|2.1|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|TML [1980]|TML [198000]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.5||||10.5|4.09|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.5||||10.5||7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|UNICARE [2040]|UNICARE [204000]|10.5||||10.5||7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.5||||10.5||7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|WEB TPA [2115]|WEB TPA [211500]|10.5||||10.5|7.25|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.5||||10.5|0|7.98|2.1
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|10.5||||10.5||7.98|2.1
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AARP [1000]|AARP [100000]|4.39||||4.39||3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AETNA [1015]|AETNA [101529]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AMBETTER [2930]|AMBETTER [293000]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.39||||4.39|2.2|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.39||||4.39|3.16|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.39||||4.39|2.2|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.39||||4.39|2.2|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.39||||4.39|3.34|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|4.39||||4.39|1.76|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.39||||4.39||3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.39||||4.39|2.2|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|Self-pay|Self-pay|4.39||||4.39|0.88|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|TML [1980]|TML [198000]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.39||||4.39|1.71|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.39||||4.39||3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UNICARE [2040]|UNICARE [204000]|4.39||||4.39||3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.39||||4.39||3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WEB TPA [2115]|WEB TPA [211500]|4.39||||4.39|3.03|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.39||||4.39|0|3.34|0.88
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|4.39||||4.39||3.34|0.88
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|1.06||||1.06||0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.06||||1.06|0.53|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.06||||1.06|0.41|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0.76|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.53|0.81|0.21
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]|1.06||||1.06|0.53|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.06||||1.06|0.81|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.06||||1.06|0.73|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.06||||1.06|0.42|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.06||||1.06||0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.06||||1.06|0.53|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.06||||1.06|0.73|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|1.06||||1.06|0.21|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|TML [1980]|TML [198000]|1.06||||1.06|0.73|0.81|0.21
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]|1.06||||1.06|0.41|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06||0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.06||||1.06||0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06||0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.06||||1.06|0.73|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06|0|0.81|0.21
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]|1.06||||1.06|0|0.81|0.21
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.06||||1.06||0.81|0.21
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|82.9||||82.9|41.45|63|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]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|82.9||||82.9|0|63|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]|82.9||||82.9|32.26|63|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]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82.9||||82.9|0.1|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82.9||||82.9|32.26|63|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]|82.9||||82.9|0|63|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]|82.9||||82.9|59.69|63|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]|82.9||||82.9|41.45|63|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]|82.9||||82.9|41.45|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82.9||||82.9|63|63|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]|82.9||||82.9|32.26|63|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]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82.9||||82.9|57.2|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|82.9||||82.9|33.16|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82.9||||82.9|41.45|63|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]|82.9||||82.9|57.2|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82.9||||82.9|0.1|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.9||||82.9|57.2|63|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]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.9||||82.9|0|63|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]|82.9||||82.9|32.26|63|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]|82.9||||82.9|0|63|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]|82.9||||82.9|0|63|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]|82.9||||82.9|32.26|63|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]|82.9||||82.9|57.2|63|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]|82.9||||82.9|32.26|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|82.9||||82.9|16.58|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|TML [1980]|TML [198000]|82.9||||82.9|57.2|63|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]|82.9||||82.9|32.26|63|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]|82.9||||82.9|41.45|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|82.9||||82.9|41.45|63|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]|82.9||||82.9|41.45|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|82.9||||82.9|57.2|63|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]|82.9||||82.9|0|63|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]|82.9||||82.9|0|63|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|82.9||||82.9|41.45|63|0.1
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|435.8||||435.8||331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMBETTER [2930]|AMBETTER [293000]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|435.8||||435.8|217.9|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|435.8||||435.8|313.78|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|435.8||||435.8|217.9|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|435.8||||435.8|217.9|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|435.8||||435.8|331.21|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA PPO [126025]|435.8||||435.8|174.32|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|435.8||||435.8||331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|435.8||||435.8|217.9|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|435.8||||435.8|87.16|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|TML [1980]|TML [198000]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|435.8||||435.8|169.61|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|435.8||||435.8||331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNICARE [2040]|UNICARE [204000]|435.8||||435.8||331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|435.8||||435.8||331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WEB TPA [2115]|WEB TPA [211500]|435.8||||435.8|300.7|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|435.8||||435.8|0|331.21|87.16
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TML WC [212537]|435.8||||435.8||331.21|87.16
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|677.43||||677.43||514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|677.43||||677.43|338.72|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|677.43||||677.43|487.75|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|677.43||||677.43|338.72|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|677.43||||677.43|338.72|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|677.43||||677.43|514.85|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|677.43||||677.43|270.97|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|677.43||||677.43||514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|677.43||||677.43|338.72|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|Self-pay|Self-pay|677.43||||677.43|135.49|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|TML [1980]|TML [198000]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|677.43||||677.43|263.66|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|677.43||||677.43||514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|677.43||||677.43||514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|677.43||||677.43||514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|677.43||||677.43|467.43|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|677.43||||677.43|0|514.85|135.49
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|677.43||||677.43||514.85|135.49
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|1412.4||||1412.4||1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1412.4||||1412.4|706.2|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1412.4||||1412.4|1016.93|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1412.4||||1412.4|706.2|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1412.4||||1412.4|706.2|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1412.4||||1412.4|1073.42|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|1412.4||||1412.4|564.96|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1412.4||||1412.4||1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1412.4||||1412.4|706.2|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|1412.4||||1412.4|282.48|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1412.4||||1412.4|549.71|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1412.4||||1412.4||1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|1412.4||||1412.4||1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1412.4||||1412.4||1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|1412.4||||1412.4|974.56|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1412.4||||1412.4|0|1073.42|282.48
7364|ERX|0250 - PHARMACY-GENERAL|SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|1412.4||||1412.4||1073.42|282.48
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AARP [1000]|AARP [100000]|684||||684|214|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AETNA [1015]|AETNA [101529]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AMBETTER [2930]|AMBETTER [293000]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|684||||684|343.79|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|684||||684|492.48|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|684||||684|342|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|684||||684|342|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|684||||684|519.84|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|CIGNA [1260]|CIGNA PPO [126025]|684||||684|273.6|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|684||||684|214|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|684||||684|343.79|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|Self-pay|Self-pay|684||||684|136.8|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|TML [1980]|TML [198000]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|684||||684|266.21|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|684||||684|214|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|UNICARE [2040]|UNICARE [204000]|684||||684|214|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|684||||684|214|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|WEB TPA [2115]|WEB TPA [211500]|684||||684|471.96|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|684||||684|0|519.84|136.8
74095700|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS|1|WORKER'S COMP [2125]|TML WC [212537]|684||||684|214|519.84|136.8
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AARP [1000]|AARP [100000]|1312||||1312|214|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AETNA [1015]|AETNA [101529]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AMBETTER [2930]|AMBETTER [293000]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1312||||1312|634.11|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1312||||1312|944.64|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1312||||1312|656|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1312||||1312|656|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1312||||1312|997.12|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|CIGNA [1260]|CIGNA PPO [126025]|1312||||1312|524.8|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1312||||1312|214|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1312||||1312|634.11|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|Self-pay|Self-pay|1312||||1312|262.4|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|TML [1980]|TML [198000]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1312||||1312|510.63|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1312||||1312|214|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|UNICARE [2040]|UNICARE [204000]|1312||||1312|214|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1312||||1312|214|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|WEB TPA [2115]|WEB TPA [211500]|1312||||1312|905.28|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1312||||1312|0|997.12|214
74095714|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC VEEG BY TECH EA INCR 12-26 HR UNMONITORED|1|WORKER'S COMP [2125]|TML WC [212537]|1312||||1312|214|997.12|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AARP [1000]|AARP [100000]|2078||||2078|214|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AETNA [1015]|AETNA [101529]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMBETTER [2930]|AMBETTER [293000]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2078||||2078|343.79|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2078||||2078|1496.16|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2078||||2078|1039|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2078||||2078|1039|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2078||||2078|1579.28|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|CIGNA [1260]|CIGNA PPO [126025]|2078||||2078|831.2|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2078||||2078|214|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2078||||2078|343.79|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|Self-pay|Self-pay|2078||||2078|415.6|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|TML [1980]|TML [198000]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2078||||2078|808.76|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2078||||2078|214|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UNICARE [2040]|UNICARE [204000]|2078||||2078|214|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2078||||2078|214|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WEB TPA [2115]|WEB TPA [211500]|2078||||2078|1433.82|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2078||||2078|0|1579.28|214
74095819|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG AWAKE/ASLEEP|1|WORKER'S COMP [2125]|TML WC [212537]|2078||||2078|214|1579.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AARP [1000]|AARP [100000]|2103||||2103|214|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AETNA [1015]|AETNA [101529]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMBETTER [2930]|AMBETTER [293000]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2103||||2103|343.79|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2103||||2103|1514.16|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2103||||2103|1051.5|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2103||||2103|1051.5|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2103||||2103|1598.28|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|CIGNA [1260]|CIGNA PPO [126025]|2103||||2103|841.2|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2103||||2103|214|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2103||||2103|343.79|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|Self-pay|Self-pay|2103||||2103|420.6|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|TML [1980]|TML [198000]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2103||||2103|818.49|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2103||||2103|214|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UNICARE [2040]|UNICARE [204000]|2103||||2103|214|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2103||||2103|214|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WEB TPA [2115]|WEB TPA [211500]|2103||||2103|1451.07|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2103||||2103|0|1598.28|214
74095822|EAP|0740 - EEG (ELECTROENCEPHALOGRAM)-GENERAL|HC EEG SLEEP ONLY|1|WORKER'S COMP [2125]|TML WC [212537]|2103||||2103|214|1598.28|214
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AARP [1000]|AARP [100000]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.34||||6.34|3.17|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.34||||6.34|4.56|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.34||||6.34|3.17|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.34||||6.34|3.17|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.34||||6.34|4.82|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|6.34||||6.34|2.54|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.34||||6.34|3.17|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|Self-pay|Self-pay|6.34||||6.34|1.27|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|TML [1980]|TML [198000]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.34||||6.34|2.47|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|6.34||||6.34|4.37|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.34||||6.34|0|75.92|1.27
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]|6.34||||6.34|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|6.34||||6.34||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|99.9||||99.9||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|99.9||||99.9|49.95|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99.9||||99.9|71.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99.9||||99.9|49.95|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99.9||||99.9|49.95|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|99.9||||99.9|75.92|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|99.9||||99.9|39.96|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|99.9||||99.9||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|99.9||||99.9|49.95|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|Self-pay|Self-pay|99.9||||99.9|19.98|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|TML [1980]|TML [198000]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99.9||||99.9|38.88|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99.9||||99.9||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|99.9||||99.9||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99.9||||99.9||75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|99.9||||99.9|68.93|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99.9||||99.9|0|75.92|1.27
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|99.9||||99.9||75.92|1.27
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.38||||2.38||1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0.93|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|1.71|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|1.19|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.19|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|1.81|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38||1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.38||||2.38|0.48|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.93|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38||1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.38||||2.38||1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38||1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38||1.81|0.48
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|28.51|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AARP [1000]|AARP [100000]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AETNA [1015]|AETNA [101529]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMBETTER [2930]|AMBETTER [293000]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|158.4||||158.4|79.2|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.4||||158.4|114.05|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.4||||158.4|79.2|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.4||||158.4|79.2|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|158.4||||158.4|120.38|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|CIGNA [1260]|CIGNA PPO [126025]|158.4||||158.4|63.36|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|158.4||||158.4|79.2|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|Self-pay|Self-pay|158.4||||158.4|31.68|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|TML [1980]|TML [198000]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.4||||158.4|61.65|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UNICARE [2040]|UNICARE [204000]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WEB TPA [2115]|WEB TPA [211500]|158.4||||158.4|109.3|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.4||||158.4|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|3,000 mL|WORKER'S COMP [2125]|TML WC [212537]|158.4||||158.4||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AARP [1000]|AARP [100000]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.6||||39.6|28.51|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|Self-pay|Self-pay|39.6||||39.6|7.92|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.6||||39.6|15.41|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6||120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.6||||39.6|0|120.38|7.92
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|500 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6||120.38|7.92
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AARP [1000]|AARP [100000]|495||||495||376.2|42.98
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]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AETNA [1015]|AETNA [101529]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AMBETTER [2930]|AMBETTER [293000]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|495||||495|192.65|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|495||||495|42.98|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|495||||495|192.65|376.2|42.98
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]|495||||495|0|376.2|42.98
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]|495||||495|356.4|376.2|42.98
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]|495||||495|247.5|376.2|42.98
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]|495||||495|247.5|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|495||||495|376.2|376.2|42.98
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]|495||||495|192.65|376.2|42.98
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]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|495||||495|341.55|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|CIGNA [1260]|CIGNA PPO [126025]|495||||495|198|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|495||||495||376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|495||||495|341.55|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|495||||495|42.98|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|495||||495|341.55|376.2|42.98
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]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|495||||495|192.65|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|495||||495|0|376.2|42.98
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]|495||||495|192.65|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|495||||495|341.55|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|495||||495|192.65|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|Self-pay|Self-pay|495||||495|99|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|TML [1980]|TML [198000]|495||||495|341.55|376.2|42.98
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]|495||||495|192.65|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|495||||495||376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UNICARE [2040]|UNICARE [204000]|495||||495||376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|495||||495||376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|WEB TPA [2115]|WEB TPA [211500]|495||||495|341.55|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|495||||495|0|376.2|42.98
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]|495||||495|0|376.2|42.98
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|WORKER'S COMP [2125]|TML WC [212537]|495||||495||376.2|42.98
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|53.31||||53.31||40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|53.31||||53.31|26.66|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|53.31||||53.31|38.38|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|53.31||||53.31|26.66|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|53.31||||53.31|26.66|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|53.31||||53.31|40.52|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|53.31||||53.31|21.32|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|53.31||||53.31||40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|53.31||||53.31|26.66|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|Self-pay|Self-pay|53.31||||53.31|10.66|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|TML [1980]|TML [198000]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|53.31||||53.31|20.75|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|53.31||||53.31||40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|53.31||||53.31||40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|53.31||||53.31||40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|53.31||||53.31|36.78|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|53.31||||53.31|0|40.52|10.66
7554|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFADIAZINE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|53.31||||53.31||40.52|10.66
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.6||||3.6||2.74|0.72
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]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.6||||3.6|1.4|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.6||||3.6|1.8|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.6||||3.6|1.4|2.74|0.72
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]|3.6||||3.6|0|2.74|0.72
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]|3.6||||3.6|2.59|2.74|0.72
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]|3.6||||3.6|1.8|2.74|0.72
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]|3.6||||3.6|1.8|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.6||||3.6|2.74|2.74|0.72
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]|3.6||||3.6|1.4|2.74|0.72
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]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.6||||3.6|2.48|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.6||||3.6|1.44|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.6||||3.6||2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.6||||3.6|2.48|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.6||||3.6|1.8|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.6||||3.6|2.48|2.74|0.72
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]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.6||||3.6|1.4|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.6||||3.6|0|2.74|0.72
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]|3.6||||3.6|1.4|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.6||||3.6|2.48|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.6||||3.6|1.4|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|3.6||||3.6|0.72|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|TML [1980]|TML [198000]|3.6||||3.6|2.48|2.74|0.72
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]|3.6||||3.6|1.4|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.6||||3.6||2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UNICARE [2040]|UNICARE [204000]|3.6||||3.6||2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.6||||3.6||2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.6||||3.6|2.48|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.6||||3.6|0|2.74|0.72
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]|3.6||||3.6|0|2.74|0.72
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.6||||3.6||2.74|0.72
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|181.07||||181.07||137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|181.07||||181.07|90.54|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.07||||181.07|130.37|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.07||||181.07|90.54|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.07||||181.07|90.54|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|181.07||||181.07|137.61|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|181.07||||181.07|72.43|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|181.07||||181.07||137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|181.07||||181.07|90.54|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|Self-pay|Self-pay|181.07||||181.07|36.21|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|TML [1980]|TML [198000]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.07||||181.07|70.47|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.07||||181.07||137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|181.07||||181.07||137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.07||||181.07||137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|181.07||||181.07|124.94|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.07||||181.07|0|137.61|36.21
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|181.07||||181.07||137.61|36.21
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|23.57||||23.57||17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMBETTER [2930]|AMBETTER [293000]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|23.57||||23.57|11.79|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.57||||23.57|16.97|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.57||||23.57|11.79|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.57||||23.57|11.79|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|23.57||||23.57|17.91|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|23.57||||23.57|9.43|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|23.57||||23.57||17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|23.57||||23.57|11.79|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|Self-pay|Self-pay|23.57||||23.57|4.71|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|TML [1980]|TML [198000]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.57||||23.57|9.17|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.57||||23.57||17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UNICARE [2040]|UNICARE [204000]|23.57||||23.57||17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.57||||23.57||17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WEB TPA [2115]|WEB TPA [211500]|23.57||||23.57|16.26|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.57||||23.57|0|17.91|4.71
76824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|23.57||||23.57||17.91|4.71
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1160.94||||1160.94|5.59|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1160.94||||1160.94|835.88|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1160.94||||1160.94|882.31|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1160.94||||1160.94|464.38|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1160.94||||1160.94|5.59|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|Self-pay|Self-pay|1160.94||||1160.94|232.19|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1160.94||||1160.94|451.84|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1160.94||||1160.94|580.47|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1160.94||||1160.94|801.05|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1160.94||||1160.94|0|882.31|5.59
76843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|APREPITANT 40 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1160.94||||1160.94|580.47|882.31|5.59
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.78||||0.78||0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.78||||0.78|0.39|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.78||||0.78|0.56|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.78||||0.78|0.39|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.78||||0.78|0.39|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.78||||0.78|0.59|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.78||||0.78|0.31|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.78||||0.78||0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.78||||0.78|0.39|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|Self-pay|Self-pay|0.78||||0.78|0.16|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|TML [1980]|TML [198000]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.78||||0.78|0.3|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.78||||0.78||0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.78||||0.78||0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.78||||0.78||0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.78||||0.78|0.54|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.78||||0.78|0|0.59|0.16
76950|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.78||||0.78||0.59|0.16
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AARP [1000]|AARP [100000]|14.85||||14.85|14.85|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AETNA [1015]|AETNA [101529]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AMBETTER [2930]|AMBETTER [293000]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.85||||14.85|80.56|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.85||||14.85|10.69|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.85||||14.85|7.43|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.85||||14.85|7.43|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.85||||14.85|11.29|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|CIGNA [1260]|CIGNA PPO [126025]|14.85||||14.85|5.94|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.85||||14.85|14.85|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.85||||14.85|80.56|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|Self-pay|Self-pay|14.85||||14.85|2.97|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|TML [1980]|TML [198000]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.85||||14.85|5.78|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.85||||14.85|14.85|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|UNICARE [2040]|UNICARE [204000]|14.85||||14.85|14.85|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.85||||14.85|14.85|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|WEB TPA [2115]|WEB TPA [211500]|14.85||||14.85|10.25|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.85||||14.85|0|80.56|2.97
77090471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC VFC IMMUNIZATION ADMIN ONE|1|WORKER'S COMP [2125]|TML WC [212537]|14.85||||14.85|14.85|80.56|2.97
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AARP [1000]|AARP [100000]|69||||69|21|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA [1015]|AETNA [101529]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|80.56|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|49.68|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|34.5|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|52.44|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|21|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|80.56|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|Self-pay|Self-pay|69||||69|13.8|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|TML [1980]|TML [198000]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|26.85|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|21|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNICARE [2040]|UNICARE [204000]|69||||69|21|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|21|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69|0|80.56|13.8
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AARP [1000]|AARP [100000]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA [1015]|AETNA [101529]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|80.56|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|49.68|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|34.5|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|52.44|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|80.56|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|Self-pay|Self-pay|69||||69|13.8|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|TML [1980]|TML [198000]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|26.85|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNICARE [2040]|UNICARE [204000]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|21|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69|0|80.56|13.8
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|21|80.56|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AARP [1000]|AARP [100000]|69||||69|21|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA [1015]|AETNA [101529]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMBETTER [2930]|AMBETTER [293000]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69||||69|52|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|49.68|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|34.5|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69||||69|52.44|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA [1260]|CIGNA PPO [126025]|69||||69|27.6|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69||||69|21|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69||||69|52|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|Self-pay|Self-pay|69||||69|13.8|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|TML [1980]|TML [198000]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|26.85|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|21|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNICARE [2040]|UNICARE [204000]|69||||69|21|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|21|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WEB TPA [2115]|WEB TPA [211500]|69||||69|47.61|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|0|52.44|13.8
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]|69||||69|0|52.44|13.8
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WORKER'S COMP [2125]|TML WC [212537]|69||||69|21|52.44|13.8
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|50.82||||50.82||38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.82||||50.82|19.78|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|50.82||||50.82|0.16|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|50.82||||50.82|19.78|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
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]|50.82||||50.82|36.59|38.62|0.16
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]|50.82||||50.82|25.41|38.62|0.16
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]|50.82||||50.82|25.41|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|50.82||||50.82|38.62|38.62|0.16
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]|50.82||||50.82|19.78|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|50.82||||50.82|35.07|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|50.82||||50.82|20.33|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|50.82||||50.82||38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|50.82||||50.82|35.07|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|50.82||||50.82|0.16|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|50.82||||50.82|35.07|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.82||||50.82|0|38.62|0.16
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]|50.82||||50.82|19.78|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.82||||50.82|0|38.62|0.16
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]|50.82||||50.82|19.78|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|50.82||||50.82|35.07|38.62|0.16
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]|50.82||||50.82|19.78|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|50.82||||50.82|10.16|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TML [1980]|TML [198000]|50.82||||50.82|35.07|38.62|0.16
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]|50.82||||50.82|19.78|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.82||||50.82||38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNICARE [2040]|UNICARE [204000]|50.82||||50.82||38.62|0.16
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]|50.82||||50.82||38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|50.82||||50.82|35.07|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
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]|50.82||||50.82|0|38.62|0.16
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|50.82||||50.82||38.62|0.16
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.21||||1.21||0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.21||||1.21|0.61|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.87|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.61|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.61|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.21||||1.21|0.92|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.21||||1.21|0.48|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.21||||1.21||0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.21||||1.21|0.61|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.21||||1.21|0.24|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.47|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21||0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.21||||1.21||0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21||0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.21||||1.21|0.83|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21|0|0.92|0.24
7753|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.21||||1.21||0.92|0.24
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|2468.4||||2468.4||1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMBETTER [2930]|AMBETTER [293000]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2468.4||||2468.4|1.42|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2468.4||||2468.4|960.7|1875.98|1.42
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]|2468.4||||2468.4|0|1875.98|1.42
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]|2468.4||||2468.4|1777.25|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2468.4||||2468.4|1234.2|1875.98|1.42
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]|2468.4||||2468.4|1234.2|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2468.4||||2468.4|1875.98|1875.98|1.42
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]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2468.4||||2468.4|1703.2|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA PPO [126025]|2468.4||||2468.4|987.36|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2468.4||||2468.4||1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2468.4||||2468.4|1703.2|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2468.4||||2468.4|1.42|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2468.4||||2468.4|1703.2|1875.98|1.42
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]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2468.4||||2468.4|0|1875.98|1.42
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]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2468.4||||2468.4|1703.2|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|2468.4||||2468.4|493.68|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|TML [1980]|TML [198000]|2468.4||||2468.4|1703.2|1875.98|1.42
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]|2468.4||||2468.4|960.7|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2468.4||||2468.4||1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNICARE [2040]|UNICARE [204000]|2468.4||||2468.4||1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2468.4||||2468.4||1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WEB TPA [2115]|WEB TPA [211500]|2468.4||||2468.4|1703.2|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2468.4||||2468.4|0|1875.98|1.42
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]|2468.4||||2468.4|0|1875.98|1.42
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TML WC [212537]|2468.4||||2468.4||1875.98|1.42
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AARP [1000]|AARP [100000]|24.42||||24.42||294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.42||||24.42|9.5|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.42||||24.42|12.21|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.42||||24.42|9.5|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
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]|24.42||||24.42|17.58|294.2|4.88
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]|24.42||||24.42|12.21|294.2|4.88
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]|24.42||||24.42|12.21|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.42||||24.42|18.56|294.2|4.88
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]|24.42||||24.42|9.5|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.42||||24.42|16.85|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|24.42||||24.42|9.77|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.42||||24.42||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.42||||24.42|16.85|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.42||||24.42|12.21|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.42||||24.42|16.85|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.42||||24.42|0|294.2|4.88
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]|24.42||||24.42|9.5|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.42||||24.42|0|294.2|4.88
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]|24.42||||24.42|9.5|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.42||||24.42|16.85|294.2|4.88
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]|24.42||||24.42|9.5|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|Self-pay|Self-pay|24.42||||24.42|4.88|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|TML [1980]|TML [198000]|24.42||||24.42|16.85|294.2|4.88
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]|24.42||||24.42|9.5|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.42||||24.42||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|24.42||||24.42||294.2|4.88
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]|24.42||||24.42||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|24.42||||24.42|16.85|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
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]|24.42||||24.42|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|24.42||||24.42||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AARP [1000]|AARP [100000]|387.11||||387.11||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AMBETTER [2930]|AMBETTER [293000]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|387.11||||387.11|193.56|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|387.11||||387.11|278.72|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|387.11||||387.11|193.56|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|387.11||||387.11|193.56|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|387.11||||387.11|294.2|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|CIGNA [1260]|CIGNA PPO [126025]|387.11||||387.11|154.84|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|387.11||||387.11||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|387.11||||387.11|193.56|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|Self-pay|Self-pay|387.11||||387.11|77.42|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|TML [1980]|TML [198000]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|387.11||||387.11|150.66|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|387.11||||387.11||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|UNICARE [2040]|UNICARE [204000]|387.11||||387.11||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|387.11||||387.11||294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|WEB TPA [2115]|WEB TPA [211500]|387.11||||387.11|267.11|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|387.11||||387.11|0|294.2|4.88
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|473 mL|WORKER'S COMP [2125]|TML WC [212537]|387.11||||387.11||294.2|4.88
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|131.34||||131.34||99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131.34||||131.34|3.3|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|94.56|99.82|3.3
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]|131.34||||131.34|65.67|99.82|3.3
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]|131.34||||131.34|65.67|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131.34||||131.34|99.82|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131.34||||131.34|90.62|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|131.34||||131.34|52.54|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131.34||||131.34||99.82|3.3
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]|131.34||||131.34|90.62|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131.34||||131.34|3.3|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131.34||||131.34|90.62|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34|90.62|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|131.34||||131.34|26.27|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|131.34||||131.34|90.62|99.82|3.3
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]|131.34||||131.34|51.12|99.82|3.3
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]|131.34||||131.34||99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|131.34||||131.34||99.82|3.3
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]|131.34||||131.34||99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|131.34||||131.34|90.62|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
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]|131.34||||131.34|0|99.82|3.3
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|131.34||||131.34||99.82|3.3
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AARP [1000]|AARP [100000]|3792.24||||3792.24||2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AETNA [1015]|AETNA [101529]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMBETTER [2930]|AMBETTER [293000]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3792.24||||3792.24|1896.12|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3792.24||||3792.24|2730.41|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3792.24||||3792.24|1896.12|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3792.24||||3792.24|1896.12|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3792.24||||3792.24|2882.1|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|CIGNA [1260]|CIGNA PPO [126025]|3792.24||||3792.24|1516.9|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3792.24||||3792.24||2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3792.24||||3792.24|1896.12|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|Self-pay|Self-pay|3792.24||||3792.24|758.45|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|TML [1980]|TML [198000]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3792.24||||3792.24|1475.94|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3792.24||||3792.24||2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UNICARE [2040]|UNICARE [204000]|3792.24||||3792.24||2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3792.24||||3792.24||2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WEB TPA [2115]|WEB TPA [211500]|3792.24||||3792.24|2616.65|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3792.24||||3792.24|0|2882.1|758.45
80000002|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC CAVH-D|1|WORKER'S COMP [2125]|TML WC [212537]|3792.24||||3792.24||2882.1|758.45
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AARP [1000]|AARP [100000]|2831.95||||2831.95||2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AETNA [1015]|AETNA [101529]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AMBETTER [2930]|AMBETTER [293000]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2831.95||||2831.95|1415.98|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2831.95||||2831.95|2039|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2831.95||||2831.95|1415.98|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2831.95||||2831.95|1415.98|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2831.95||||2831.95|2152.28|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|CIGNA [1260]|CIGNA PPO [126025]|2831.95||||2831.95|1132.78|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2831.95||||2831.95||2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2831.95||||2831.95|1415.98|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|Self-pay|Self-pay|2831.95||||2831.95|566.39|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|TML [1980]|TML [198000]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2831.95||||2831.95|1102.19|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2831.95||||2831.95||2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|UNICARE [2040]|UNICARE [204000]|2831.95||||2831.95||2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2831.95||||2831.95||2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|WEB TPA [2115]|WEB TPA [211500]|2831.95||||2831.95|1954.05|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2831.95||||2831.95|0|2152.28|566.39
80000003|EAP|0800 - INPATIENT RENAL DIALYSIS-GENERAL|HC DIALYSIS INPATIENT ONE ON ONE|1|WORKER'S COMP [2125]|TML WC [212537]|2831.95||||2831.95||2152.28|566.39
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AARP [1000]|AARP [100000]|1540||||1540||1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AETNA [1015]|AETNA [101529]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMBETTER [2930]|AMBETTER [293000]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1540||||1540|770|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1540||||1540|1108.8|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1540||||1540|770|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1540||||1540|770|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1540||||1540|1170.4|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|CIGNA [1260]|CIGNA PPO [126025]|1540||||1540|616|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1540||||1540||1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1540||||1540|770|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|Self-pay|Self-pay|1540||||1540|308|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|TML [1980]|TML [198000]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1540||||1540|599.37|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1540||||1540||1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UNICARE [2040]|UNICARE [204000]|1540||||1540||1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1540||||1540||1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WEB TPA [2115]|WEB TPA [211500]|1540||||1540|1062.6|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1540||||1540|0|1170.4|308
80100006|EAP|0801 - INPATIENT RENAL DIALYSIS-INPATIENT HEMODIAL|HC HEMODIALYSIS ACUTE|1|WORKER'S COMP [2125]|TML WC [212537]|1540||||1540||1170.4|308
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|40.4||||40.4||30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|40.4||||40.4|20.2|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.4||||40.4|29.09|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.4||||40.4|20.2|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.4||||40.4|20.2|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|40.4||||40.4|30.7|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|40.4||||40.4|16.16|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|40.4||||40.4||30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|40.4||||40.4|20.2|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|40.4||||40.4|8.08|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.4||||40.4|15.72|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.4||||40.4||30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|40.4||||40.4||30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.4||||40.4||30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|40.4||||40.4|27.88|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.4||||40.4|0|30.7|8.08
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|40.4||||40.4||30.7|8.08
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|61.38||||61.38||46.65|12.28
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]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMBETTER [2930]|AMBETTER [293000]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|61.38||||61.38|23.89|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|61.38||||61.38|30.69|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|61.38||||61.38|23.89|46.65|12.28
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]|61.38||||61.38|0|46.65|12.28
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]|61.38||||61.38|44.19|46.65|12.28
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]|61.38||||61.38|30.69|46.65|12.28
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]|61.38||||61.38|30.69|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|61.38||||61.38|46.65|46.65|12.28
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]|61.38||||61.38|23.89|46.65|12.28
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]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|61.38||||61.38|42.35|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA PPO [126025]|61.38||||61.38|24.55|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|61.38||||61.38||46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|61.38||||61.38|42.35|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|61.38||||61.38|30.69|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|61.38||||61.38|42.35|46.65|12.28
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]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|61.38||||61.38|23.89|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|61.38||||61.38|0|46.65|12.28
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]|61.38||||61.38|23.89|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|61.38||||61.38|42.35|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|61.38||||61.38|23.89|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|61.38||||61.38|12.28|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|TML [1980]|TML [198000]|61.38||||61.38|42.35|46.65|12.28
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]|61.38||||61.38|23.89|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|61.38||||61.38||46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNICARE [2040]|UNICARE [204000]|61.38||||61.38||46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|61.38||||61.38||46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WEB TPA [2115]|WEB TPA [211500]|61.38||||61.38|42.35|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|61.38||||61.38|0|46.65|12.28
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]|61.38||||61.38|0|46.65|12.28
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TML WC [212537]|61.38||||61.38||46.65|12.28
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|59.6||||59.6||45.3|11.92
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]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMBETTER [2930]|AMBETTER [293000]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.6||||59.6|23.2|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.6||||59.6|29.8|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.6||||59.6|23.2|45.3|11.92
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]|59.6||||59.6|0|45.3|11.92
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]|59.6||||59.6|42.91|45.3|11.92
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]|59.6||||59.6|29.8|45.3|11.92
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]|59.6||||59.6|29.8|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.6||||59.6|45.3|45.3|11.92
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]|59.6||||59.6|23.2|45.3|11.92
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]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.6||||59.6|41.12|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA PPO [126025]|59.6||||59.6|23.84|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.6||||59.6||45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|59.6||||59.6|41.12|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.6||||59.6|29.8|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.6||||59.6|41.12|45.3|11.92
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]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.6||||59.6|23.2|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.6||||59.6|0|45.3|11.92
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]|59.6||||59.6|23.2|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|59.6||||59.6|41.12|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.6||||59.6|23.2|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|59.6||||59.6|11.92|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|TML [1980]|TML [198000]|59.6||||59.6|41.12|45.3|11.92
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]|59.6||||59.6|23.2|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.6||||59.6||45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNICARE [2040]|UNICARE [204000]|59.6||||59.6||45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.6||||59.6||45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WEB TPA [2115]|WEB TPA [211500]|59.6||||59.6|41.12|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.6||||59.6|0|45.3|11.92
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]|59.6||||59.6|0|45.3|11.92
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TML WC [212537]|59.6||||59.6||45.3|11.92
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|106.79||||106.79|1.79|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|106.79||||106.79|1.79|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|106.79||||106.79|41.56|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|76.89|81.16|1.79
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]|106.79||||106.79|76.89|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|106.79||||106.79|81.16|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|106.79||||106.79|81.16|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|106.79||||106.79|42.72|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|106.79||||106.79|42.72|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|73.69|81.16|1.79
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]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|106.79||||106.79|1.79|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|106.79||||106.79|1.79|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|106.79||||106.79|73.69|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|106.79||||106.79|73.69|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|106.79||||106.79|21.36|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|106.79||||106.79|21.36|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TML [1980]|TML [198000]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TML [1980]|TML [198000]|106.79||||106.79|73.69|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|41.56|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNICARE [2040]|UNICARE [204000]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
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]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|106.79||||106.79|73.69|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|106.79||||106.79|73.69|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
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]|106.79||||106.79|0|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|106.79||||106.79|53.4|81.16|1.79
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|106.79||||106.79|53.4|81.16|1.79
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.63||||3.63|1.82|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|2.61|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
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]|3.63||||3.63|1.82|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.63||||3.63|2.76|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.63||||3.63|2.5|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.63||||3.63|1.45|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63|2.5|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.63||||3.63|1.82|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.63||||3.63|0.73|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|1.41|2.76|0.73
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]|3.63||||3.63||2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.63||||3.63||2.76|0.73
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]|3.63||||3.63||2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.63||||3.63|2.5|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
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]|3.63||||3.63|0|2.76|0.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.63||||3.63||2.76|0.73
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AARP [1000]|AARP [100000]|52.8||||52.8||40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|26.4|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.8||||52.8|38.02|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.8||||52.8|26.4|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.8||||52.8|26.4|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|40.13|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8||40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|26.4|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|Self-pay|Self-pay|52.8||||52.8|10.56|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.8||||52.8|20.55|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8||40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8||40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8||40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.8||||52.8|0|40.13|10.56
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|8 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8||40.13|10.56
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AARP [1000]|AARP [100000]|8.35||||8.35||6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AETNA [1015]|AETNA [101529]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AMBETTER [2930]|AMBETTER [293000]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.35||||8.35|4.18|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.35||||8.35|6.01|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.35||||8.35|4.18|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.35||||8.35|4.18|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.35||||8.35|6.35|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|8.35||||8.35|3.34|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.35||||8.35||6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.35||||8.35|4.18|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|Self-pay|Self-pay|8.35||||8.35|1.67|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|TML [1980]|TML [198000]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.35||||8.35|3.25|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.35||||8.35||6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UNICARE [2040]|UNICARE [204000]|8.35||||8.35||6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.35||||8.35||6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WEB TPA [2115]|WEB TPA [211500]|8.35||||8.35|5.76|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.35||||8.35|0|6.35|1.67
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|8.35||||8.35||6.35|1.67
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|27.72|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|27.72|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.5||||38.5|27.72|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|29.26|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|29.26|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|38.5||||38.5|29.26|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|38.5||||38.5|15.4|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|38.5||||38.5|19.25|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|38.5||||38.5|7.7|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.5||||38.5|14.98|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|38.5||||38.5|26.57|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.5||||38.5|0|29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5||29.26|7.7
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|38.5||||38.5||29.26|7.7
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|301.76||||301.76||229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|301.76||||301.76|150.88|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|301.76||||301.76|217.27|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|301.76||||301.76|150.88|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|301.76||||301.76|150.88|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|301.76||||301.76|229.34|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|301.76||||301.76|120.7|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|301.76||||301.76||229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|301.76||||301.76|150.88|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|301.76||||301.76|60.35|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|301.76||||301.76|117.44|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|301.76||||301.76||229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|301.76||||301.76||229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|301.76||||301.76||229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|301.76||||301.76|208.21|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|301.76||||301.76|0|229.34|60.35
82504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMBETTER [2930]|AMBETTER [293000]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|301.76||||301.76|150.88|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|301.76||||301.76|217.27|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|301.76||||301.76|150.88|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|301.76||||301.76|150.88|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|301.76||||301.76|229.34|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA - GREAT WEST [126009]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA PPO [126025]|301.76||||301.76|120.7|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|301.76||||301.76|150.88|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|301.76||||301.76|60.35|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|TML [1980]|TML [198000]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|301.76||||301.76|117.44|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UNICARE [2040]|UNICARE [204000]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|301.76||||301.76||229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WEB TPA [2115]|WEB TPA [211500]|301.76||||301.76|208.21|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|301.76||||301.76|0|229.34|60.35
82505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TML WC [212537]|301.76||||301.76||229.34|60.35
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|118.44||||118.44||90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMBETTER [2930]|AMBETTER [293000]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|118.44||||118.44|59.22|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|118.44||||118.44|46.1|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|85.28|90.01|23.69
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]|118.44||||118.44|59.22|90.01|23.69
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]|118.44||||118.44|59.22|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|118.44||||118.44|90.01|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|118.44||||118.44|81.72|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA PPO [126025]|118.44||||118.44|47.38|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|118.44||||118.44||90.01|23.69
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]|118.44||||118.44|81.72|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|118.44||||118.44|59.22|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|118.44||||118.44|81.72|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.44||||118.44|81.72|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|118.44||||118.44|23.69|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|TML [1980]|TML [198000]|118.44||||118.44|81.72|90.01|23.69
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]|118.44||||118.44|46.1|90.01|23.69
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]|118.44||||118.44||90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNICARE [2040]|UNICARE [204000]|118.44||||118.44||90.01|23.69
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]|118.44||||118.44||90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WEB TPA [2115]|WEB TPA [211500]|118.44||||118.44|81.72|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
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]|118.44||||118.44|0|90.01|23.69
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TML WC [212537]|118.44||||118.44||90.01|23.69
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|2.64||||2.64||2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMBETTER [2930]|AMBETTER [293000]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.64||||2.64|1.32|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.9|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.32|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.32|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.64||||2.64|2.01|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA PPO [126025]|2.64||||2.64|1.06|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.64||||2.64||2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.64||||2.64|1.32|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|2.64||||2.64|0.53|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|TML [1980]|TML [198000]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|1.03|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64||2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNICARE [2040]|UNICARE [204000]|2.64||||2.64||2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64||2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WEB TPA [2115]|WEB TPA [211500]|2.64||||2.64|1.82|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.64||||2.64|0|2.01|0.53
8428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TML WC [212537]|2.64||||2.64||2.01|0.53
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.28||||5.28||4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.28||||5.28|2.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.28||||5.28|3.8|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.28||||5.28|2.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.28||||5.28|2.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.28||||5.28|4.01|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|5.28||||5.28|2.11|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.28||||5.28||4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.28||||5.28|2.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.28||||5.28|1.06|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.28||||5.28|2.05|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.28||||5.28||4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|5.28||||5.28||4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.28||||5.28||4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|5.28||||5.28|3.64|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.28||||5.28|0|4.01|1.06
8429|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|5.28||||5.28||4.01|1.06
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AARP [1000]|AARP [100000]|209.88||||209.88|104.94|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMBETTER [2930]|AMBETTER [293000]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209.88||||209.88|81.69|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|209.88||||209.88|3.39|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|209.88||||209.88|81.69|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
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]|209.88||||209.88|151.11|159.51|3.39
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]|209.88||||209.88|104.94|159.51|3.39
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]|209.88||||209.88|104.94|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|209.88||||209.88|159.51|159.51|3.39
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]|209.88||||209.88|81.69|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|209.88||||209.88|144.82|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA [1260]|CIGNA PPO [126025]|209.88||||209.88|83.95|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|209.88||||209.88|104.94|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|209.88||||209.88|144.82|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|209.88||||209.88|3.39|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|209.88||||209.88|144.82|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209.88||||209.88|0|159.51|3.39
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]|209.88||||209.88|81.69|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209.88||||209.88|0|159.51|3.39
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]|209.88||||209.88|81.69|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|209.88||||209.88|144.82|159.51|3.39
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]|209.88||||209.88|81.69|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|Self-pay|Self-pay|209.88||||209.88|41.98|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|TML [1980]|TML [198000]|209.88||||209.88|144.82|159.51|3.39
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]|209.88||||209.88|81.69|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209.88||||209.88|104.94|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNICARE [2040]|UNICARE [204000]|209.88||||209.88|104.94|159.51|3.39
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]|209.88||||209.88|104.94|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WEB TPA [2115]|WEB TPA [211500]|209.88||||209.88|144.82|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
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]|209.88||||209.88|0|159.51|3.39
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WORKER'S COMP [2125]|TML WC [212537]|209.88||||209.88|104.94|159.51|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|3.39|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|3.39
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]|92.4||||92.4|0|70.22|3.39
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]|92.4||||92.4|66.53|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|46.2|70.22|3.39
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]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|3.39
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]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|3.39|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|3.39
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]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|0|70.22|3.39
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]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|92.4||||92.4|18.48|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|3.39
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]|92.4||||92.4|35.96|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|46.2|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4|0|70.22|3.39
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]|92.4||||92.4|0|70.22|3.39
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|46.2|70.22|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AARP [1000]|AARP [100000]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA [1015]|AETNA [101529]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMBETTER [2930]|AMBETTER [293000]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1049.4||||1049.4|3.39|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1049.4||||1049.4|408.43|797.54|3.39
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]|1049.4||||1049.4|0|797.54|3.39
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]|1049.4||||1049.4|755.57|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1049.4||||1049.4|524.7|797.54|3.39
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]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1049.4||||1049.4|797.54|797.54|3.39
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]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1049.4||||1049.4|724.09|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA [1260]|CIGNA PPO [126025]|1049.4||||1049.4|419.76|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1049.4||||1049.4|724.09|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1049.4||||1049.4|3.39|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1049.4||||1049.4|724.09|797.54|3.39
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]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1049.4||||1049.4|0|797.54|3.39
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]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1049.4||||1049.4|724.09|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|Self-pay|Self-pay|1049.4||||1049.4|209.88|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|TML [1980]|TML [198000]|1049.4||||1049.4|724.09|797.54|3.39
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]|1049.4||||1049.4|408.43|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNICARE [2040]|UNICARE [204000]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1049.4||||1049.4|524.7|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WEB TPA [2115]|WEB TPA [211500]|1049.4||||1049.4|724.09|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1049.4||||1049.4|0|797.54|3.39
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]|1049.4||||1049.4|0|797.54|3.39
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WORKER'S COMP [2125]|TML WC [212537]|1049.4||||1049.4|524.7|797.54|3.39
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|18.75||||18.75||14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.75||||18.75|9.38|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.75||||18.75|13.5|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.75||||18.75|9.38|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.75||||18.75|9.38|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.75||||18.75|14.25|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|18.75||||18.75|7.5|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.75||||18.75||14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.75||||18.75|9.38|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|18.75||||18.75|3.75|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|TML [1980]|TML [198000]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.75||||18.75|7.3|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.75||||18.75||14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|18.75||||18.75||14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.75||||18.75||14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|18.75||||18.75|12.94|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.75||||18.75|0|14.25|3.75
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]|18.75||||18.75|0|14.25|3.75
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|18.75||||18.75||14.25|3.75
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]|302.57||||302.57||229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMBETTER [2930]|AMBETTER [293000]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|302.57||||302.57|151.29|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|217.85|229.95|60.51
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]|302.57||||302.57|151.29|229.95|60.51
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]|302.57||||302.57|151.29|229.95|60.51
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 TRADITIONAL OF TEXAS [115503]|302.57||||302.57|229.95|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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 - GREAT WEST [126009]|302.57||||302.57|208.77|229.95|60.51
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 PPO [126025]|302.57||||302.57|121.03|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|302.57||||302.57||229.95|60.51
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]|302.57||||302.57|208.77|229.95|60.51
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]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|302.57||||302.57|151.29|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|302.57||||302.57|208.77|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57|208.77|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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|302.57||||302.57|60.51|229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|TML [1980]|TML [198000]|302.57||||302.57|208.77|229.95|60.51
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]|302.57||||302.57|117.76|229.95|60.51
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]|302.57||||302.57||229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNICARE [2040]|UNICARE [204000]|302.57||||302.57||229.95|60.51
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]|302.57||||302.57||229.95|60.51
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WEB TPA [2115]|WEB TPA [211500]|302.57||||302.57|208.77|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|302.57||||302.57|0|229.95|60.51
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]|TML WC [212537]|302.57||||302.57||229.95|60.51
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.95||||3.95||3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.95||||3.95|1.98|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.95||||3.95|1.54|3|0.79
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]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.95||||3.95|2.84|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.95||||3.95|1.98|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.95||||3.95|1.98|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.95||||3.95|3|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.95||||3.95|2.73|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.95||||3.95|1.58|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.95||||3.95||3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.95||||3.95|2.73|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.95||||3.95|1.98|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.95||||3.95|2.73|3|0.79
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]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.95||||3.95|0|3|0.79
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]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.95||||3.95|2.73|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.95||||3.95|0.79|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.95||||3.95|2.73|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.95||||3.95|1.54|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.95||||3.95||3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.95||||3.95||3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.95||||3.95||3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.95||||3.95|2.73|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.95||||3.95|0|3|0.79
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]|3.95||||3.95|0|3|0.79
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.95||||3.95||3|0.79
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|1320.27||||1320.27||1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AMBETTER [2930]|AMBETTER [293000]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1320.27||||1320.27|660.14|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1320.27||||1320.27|513.85|1003.41|264.05
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]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1320.27||||1320.27|950.59|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1320.27||||1320.27|660.14|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1320.27||||1320.27|660.14|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1320.27||||1320.27|1003.41|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1320.27||||1320.27|910.99|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA PPO [126025]|1320.27||||1320.27|528.11|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1320.27||||1320.27||1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1320.27||||1320.27|910.99|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1320.27||||1320.27|660.14|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1320.27||||1320.27|910.99|1003.41|264.05
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]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1320.27||||1320.27|0|1003.41|264.05
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]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1320.27||||1320.27|910.99|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|1320.27||||1320.27|264.05|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|TML [1980]|TML [198000]|1320.27||||1320.27|910.99|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1320.27||||1320.27|513.85|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1320.27||||1320.27||1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UNICARE [2040]|UNICARE [204000]|1320.27||||1320.27||1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1320.27||||1320.27||1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|WEB TPA [2115]|WEB TPA [211500]|1320.27||||1320.27|910.99|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1320.27||||1320.27|0|1003.41|264.05
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]|1320.27||||1320.27|0|1003.41|264.05
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TML WC [212537]|1320.27||||1320.27||1003.41|264.05
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|14.52||||14.52||11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|14.52||||14.52|7.26|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|14.52||||14.52|5.65|11.04|2.9
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]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.52||||14.52|10.45|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.52||||14.52|7.26|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.52||||14.52|7.26|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|14.52||||14.52|11.04|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|14.52||||14.52|10.02|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|14.52||||14.52|5.81|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|14.52||||14.52||11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.52||||14.52|10.02|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|14.52||||14.52|7.26|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|14.52||||14.52|10.02|11.04|2.9
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]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.52||||14.52|0|11.04|2.9
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]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.52||||14.52|10.02|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|14.52||||14.52|2.9|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|14.52||||14.52|10.02|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.52||||14.52|5.65|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.52||||14.52||11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|14.52||||14.52||11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.52||||14.52||11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|14.52||||14.52|10.02|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.52||||14.52|0|11.04|2.9
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]|14.52||||14.52|0|11.04|2.9
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|14.52||||14.52||11.04|2.9
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|381.75||||381.75||290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|381.75||||381.75|190.88|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.75||||381.75|274.86|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.75||||381.75|190.88|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.75||||381.75|190.88|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|381.75||||381.75|290.13|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|381.75||||381.75|152.7|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|381.75||||381.75||290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|381.75||||381.75|190.88|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|Self-pay|Self-pay|381.75||||381.75|76.35|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|TML [1980]|TML [198000]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.75||||381.75|148.58|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.75||||381.75||290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|381.75||||381.75||290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.75||||381.75||290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|381.75||||381.75|263.41|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.75||||381.75|0|290.13|76.35
88608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALTEGRAVIR 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|381.75||||381.75||290.13|76.35
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|183.93||||183.93||139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|183.93||||183.93|91.97|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183.93||||183.93|132.43|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183.93||||183.93|91.97|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183.93||||183.93|91.97|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|183.93||||183.93|139.79|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|183.93||||183.93|73.57|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|183.93||||183.93||139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|183.93||||183.93|91.97|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|Self-pay|Self-pay|183.93||||183.93|36.79|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183.93||||183.93|71.59|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183.93||||183.93||139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|183.93||||183.93||139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183.93||||183.93||139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|183.93||||183.93|126.91|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183.93||||183.93|0|139.79|36.79
88704|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|183.93||||183.93||139.79|36.79
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.14||||5.14||3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5.14||||5.14|2.57|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.14||||5.14|3.7|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.14||||5.14|2.57|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.14||||5.14|2.57|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5.14||||5.14|3.91|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|5.14||||5.14|2.06|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5.14||||5.14||3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5.14||||5.14|2.57|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|Self-pay|Self-pay|5.14||||5.14|1.03|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|TML [1980]|TML [198000]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.14||||5.14|2|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.14||||5.14||3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|5.14||||5.14||3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.14||||5.14||3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|5.14||||5.14|3.55|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.14||||5.14|0|3.91|1.03
89201|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 800 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|5.14||||5.14||3.91|1.03
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|69.49||||69.49||52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|69.49||||69.49|34.75|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|69.49||||69.49|27.05|52.81|13.9
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]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.49||||69.49|50.03|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.49||||69.49|34.75|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.49||||69.49|34.75|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|69.49||||69.49|52.81|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|69.49||||69.49|47.95|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|69.49||||69.49|27.8|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|69.49||||69.49||52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|69.49||||69.49|47.95|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|69.49||||69.49|34.75|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|69.49||||69.49|47.95|52.81|13.9
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]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.49||||69.49|0|52.81|13.9
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]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|69.49||||69.49|47.95|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|69.49||||69.49|13.9|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|69.49||||69.49|47.95|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.49||||69.49|27.05|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.49||||69.49||52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|69.49||||69.49||52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.49||||69.49||52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|69.49||||69.49|47.95|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.49||||69.49|0|52.81|13.9
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]|69.49||||69.49|0|52.81|13.9
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|69.49||||69.49||52.81|13.9
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AARP [1000]|AARP [100000]|1135.2||||1135.2||862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AETNA [1015]|AETNA [101529]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AMBETTER [2930]|AMBETTER [293000]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1135.2||||1135.2|567.6|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1135.2||||1135.2|441.82|862.75|227.04
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]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1135.2||||1135.2|817.34|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1135.2||||1135.2|567.6|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1135.2||||1135.2|567.6|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1135.2||||1135.2|862.75|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1135.2||||1135.2|783.29|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA [1260]|CIGNA PPO [126025]|1135.2||||1135.2|454.08|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1135.2||||1135.2||862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|GROUP PENSION ADMIN [1450]|GPA [145000]|1135.2||||1135.2|783.29|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1135.2||||1135.2|567.6|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1135.2||||1135.2|783.29|862.75|227.04
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]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1135.2||||1135.2|0|862.75|227.04
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]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|PHCS [1780]|PHCS MULTIPLAN [178000]|1135.2||||1135.2|783.29|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|Self-pay|Self-pay|1135.2||||1135.2|227.04|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|TML [1980]|TML [198000]|1135.2||||1135.2|783.29|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1135.2||||1135.2|441.82|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1135.2||||1135.2||862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UNICARE [2040]|UNICARE [204000]|1135.2||||1135.2||862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1135.2||||1135.2||862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|WEB TPA [2115]|WEB TPA [211500]|1135.2||||1135.2|783.29|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1135.2||||1135.2|0|862.75|227.04
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]|1135.2||||1135.2|0|862.75|227.04
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|WORKER'S COMP [2125]|TML WC [212537]|1135.2||||1135.2||862.75|227.04
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]|21.47||||21.47||16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.47||||21.47|10.74|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|15.46|16.32|4.29
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]|21.47||||21.47|10.74|16.32|4.29
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]|21.47||||21.47|10.74|16.32|4.29
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 TRADITIONAL OF TEXAS [115503]|21.47||||21.47|16.32|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.47||||21.47|14.81|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|21.47||||21.47|8.59|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.47||||21.47||16.32|4.29
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]|21.47||||21.47|14.81|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.47||||21.47|10.74|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.47||||21.47|14.81|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47|14.81|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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|21.47||||21.47|4.29|16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|TML [1980]|TML [198000]|21.47||||21.47|14.81|16.32|4.29
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]|21.47||||21.47|8.36|16.32|4.29
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]|21.47||||21.47||16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|21.47||||21.47||16.32|4.29
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]|21.47||||21.47||16.32|4.29
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|21.47||||21.47|14.81|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|21.47||||21.47|0|16.32|4.29
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]|TML WC [212537]|21.47||||21.47||16.32|4.29
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|52.8||||52.8||40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|52.8||||52.8|26.4|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.8||||52.8|38.02|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.8||||52.8|26.4|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.8||||52.8|26.4|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|52.8||||52.8|40.13|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|52.8||||52.8|21.12|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|52.8||||52.8||40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|52.8||||52.8|26.4|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|52.8||||52.8|10.56|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|TML [1980]|TML [198000]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.8||||52.8|20.55|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.8||||52.8||40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|52.8||||52.8||40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.8||||52.8||40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|52.8||||52.8|36.43|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.8||||52.8|0|40.13|10.56
8963|ERX|0250 - PHARMACY-GENERAL|ACETIC ACID 0.25 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|52.8||||52.8||40.13|10.56
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.38||||2.38||1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.38||||2.38|1.19|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.38||||2.38|0.93|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|1.71|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|1.19|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.19|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.38||||2.38|1.81|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.38||||2.38|1.64|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.38||||2.38|0.95|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.38||||2.38||1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.38||||2.38|1.19|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.38||||2.38|1.64|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.38||||2.38|0.48|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.38||||2.38|1.64|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.93|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38||1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.38||||2.38||1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38||1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.38||||2.38|1.64|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38|0|1.81|0.48
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]|2.38||||2.38|0|1.81|0.48
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.38||||2.38||1.81|0.48
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMBETTER [2930]|AMBETTER [293000]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|763.62||||763.62|68.19|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|763.62||||763.62|549.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|763.62||||763.62|580.35|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA PPO [126025]|763.62||||763.62|305.45|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|763.62||||763.62|68.19|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|763.62||||763.62|152.72|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|TML [1980]|TML [198000]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|763.62||||763.62|297.2|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UNICARE [2040]|UNICARE [204000]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|763.62||||763.62|381.81|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WEB TPA [2115]|WEB TPA [211500]|763.62||||763.62|526.9|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|763.62||||763.62|0|580.35|68.19
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TML WC [212537]|763.62||||763.62|381.81|580.35|68.19
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AARP [1000]|AARP [100000]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMBETTER [2930]|AMBETTER [293000]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|762.3||||762.3|13.64|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|762.3||||762.3|296.69|579.35|13.64
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]|762.3||||762.3|0|579.35|13.64
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]|762.3||||762.3|548.86|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|762.3||||762.3|381.15|579.35|13.64
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]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|762.3||||762.3|579.35|579.35|13.64
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]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|762.3||||762.3|525.99|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA PPO [126025]|762.3||||762.3|304.92|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|762.3||||762.3|525.99|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|762.3||||762.3|13.64|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|762.3||||762.3|525.99|579.35|13.64
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]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|762.3||||762.3|0|579.35|13.64
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]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|762.3||||762.3|525.99|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|Self-pay|Self-pay|762.3||||762.3|152.46|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|TML [1980]|TML [198000]|762.3||||762.3|525.99|579.35|13.64
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]|762.3||||762.3|296.69|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNICARE [2040]|UNICARE [204000]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|762.3||||762.3|381.15|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WEB TPA [2115]|WEB TPA [211500]|762.3||||762.3|525.99|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|762.3||||762.3|0|579.35|13.64
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]|762.3||||762.3|0|579.35|13.64
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TML WC [212537]|762.3||||762.3|381.15|579.35|13.64
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|58082.38||||58082.38||44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AMBETTER [2930]|AMBETTER [293000]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|58082.38||||58082.38|113.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58082.38||||58082.38|41819.31|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58082.38||||58082.38|29041.19|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58082.38||||58082.38|29041.19|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|58082.38||||58082.38|44142.61|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA PPO [126025]|58082.38||||58082.38|29041.19|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|58082.38||||58082.38||44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|58082.38||||58082.38|113.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|58082.38||||58082.38|11616.48|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|TML [1980]|TML [198000]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58082.38||||58082.38|22605.66|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58082.38||||58082.38||44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|UNICARE [2040]|UNICARE [204000]|58082.38||||58082.38||44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58082.38||||58082.38||44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|WEB TPA [2115]|WEB TPA [211500]|58082.38||||58082.38|40076.84|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58082.38||||58082.38|0|44142.61|113.66
9003|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TML WC [212537]|58082.38||||58082.38||44142.61|113.66
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.89||||4.89||3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.89||||4.89|2.45|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.89||||4.89|1.9|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.89||||4.89|3.52|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.89||||4.89|2.45|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.89||||4.89|2.45|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.89||||4.89|3.72|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.89||||4.89|3.37|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.89||||4.89|1.96|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.89||||4.89||3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.89||||4.89|3.37|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.89||||4.89|2.45|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.89||||4.89|3.37|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.89||||4.89|0|3.72|0.98
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]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.89||||4.89|3.37|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|4.89||||4.89|0.98|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.89||||4.89|3.37|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.89||||4.89|1.9|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.89||||4.89||3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.89||||4.89||3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.89||||4.89||3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.89||||4.89|3.37|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.89||||4.89|0|3.72|0.98
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]|4.89||||4.89|0|3.72|0.98
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.89||||4.89||3.72|0.98
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.26||||2.26||1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.26||||2.26|1.13|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.26||||2.26|0.88|1.72|0.45
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]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.26||||2.26|1.63|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.26||||2.26|1.13|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.26||||2.26|1.13|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.26||||2.26|1.72|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.26||||2.26|1.56|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|2.26||||2.26|0.9|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.26||||2.26||1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.26||||2.26|1.56|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.26||||2.26|1.13|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.26||||2.26|1.56|1.72|0.45
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]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.26||||2.26|0|1.72|0.45
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]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.26||||2.26|1.56|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.26||||2.26|0.45|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|2.26||||2.26|1.56|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.26||||2.26|0.88|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.26||||2.26||1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|2.26||||2.26||1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.26||||2.26||1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|2.26||||2.26|1.56|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.26||||2.26|0|1.72|0.45
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]|2.26||||2.26|0|1.72|0.45
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|2.26||||2.26||1.72|0.45
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AARP [1000]|AARP [100000]|683.1||||683.1||519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AETNA [1015]|AETNA [101529]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMBETTER [2930]|AMBETTER [293000]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|683.1||||683.1|341.55|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|683.1||||683.1|491.83|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|683.1||||683.1|341.55|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|683.1||||683.1|341.55|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|683.1||||683.1|519.16|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|CIGNA [1260]|CIGNA PPO [126025]|683.1||||683.1|273.24|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|683.1||||683.1||519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|683.1||||683.1|341.55|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|Self-pay|Self-pay|683.1||||683.1|136.62|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|TML [1980]|TML [198000]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|683.1||||683.1|265.86|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|683.1||||683.1||519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UNICARE [2040]|UNICARE [204000]|683.1||||683.1||519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|683.1||||683.1||519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WEB TPA [2115]|WEB TPA [211500]|683.1||||683.1|471.34|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|683.1||||683.1|0|519.16|136.62
9080|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION|75 mL|WORKER'S COMP [2125]|TML WC [212537]|683.1||||683.1||519.16|136.62
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AARP [1000]|AARP [100000]|100.8||||100.8|50.4|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AETNA [1015]|AETNA [101529]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMBETTER [2930]|AMBETTER [293000]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|100.8||||100.8|3.2|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|72.58|76.61|3.2
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]|100.8||||100.8|50.4|76.61|3.2
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]|100.8||||100.8|50.4|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|100.8||||100.8|76.61|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|100.8||||100.8|69.55|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA [1260]|CIGNA PPO [126025]|100.8||||100.8|40.32|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|100.8||||100.8|50.4|76.61|3.2
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]|100.8||||100.8|69.55|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|100.8||||100.8|3.2|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|100.8||||100.8|69.55|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|69.55|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|Self-pay|Self-pay|100.8||||100.8|20.16|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|TML [1980]|TML [198000]|100.8||||100.8|69.55|76.61|3.2
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]|100.8||||100.8|39.23|76.61|3.2
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]|100.8||||100.8|50.4|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNICARE [2040]|UNICARE [204000]|100.8||||100.8|50.4|76.61|3.2
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]|100.8||||100.8|50.4|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WEB TPA [2115]|WEB TPA [211500]|100.8||||100.8|69.55|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
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]|100.8||||100.8|0|76.61|3.2
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WORKER'S COMP [2125]|TML WC [212537]|100.8||||100.8|50.4|76.61|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AARP [1000]|AARP [100000]|190.32||||190.32|95.16|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AETNA [1015]|AETNA [101529]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMBETTER [2930]|AMBETTER [293000]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190.32||||190.32|74.07|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|190.32||||190.32|3.2|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|190.32||||190.32|74.07|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
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]|190.32||||190.32|137.03|144.64|3.2
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]|190.32||||190.32|95.16|144.64|3.2
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]|190.32||||190.32|95.16|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|190.32||||190.32|144.64|144.64|3.2
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]|190.32||||190.32|74.07|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|190.32||||190.32|131.32|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA [1260]|CIGNA PPO [126025]|190.32||||190.32|76.13|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|190.32||||190.32|95.16|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|GROUP PENSION ADMIN [1450]|GPA [145000]|190.32||||190.32|131.32|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|190.32||||190.32|3.2|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|190.32||||190.32|131.32|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190.32||||190.32|0|144.64|3.2
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]|190.32||||190.32|74.07|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190.32||||190.32|0|144.64|3.2
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]|190.32||||190.32|74.07|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|PHCS [1780]|PHCS MULTIPLAN [178000]|190.32||||190.32|131.32|144.64|3.2
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]|190.32||||190.32|74.07|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|Self-pay|Self-pay|190.32||||190.32|38.06|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|TML [1980]|TML [198000]|190.32||||190.32|131.32|144.64|3.2
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]|190.32||||190.32|74.07|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190.32||||190.32|95.16|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNICARE [2040]|UNICARE [204000]|190.32||||190.32|95.16|144.64|3.2
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]|190.32||||190.32|95.16|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WEB TPA [2115]|WEB TPA [211500]|190.32||||190.32|131.32|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
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]|190.32||||190.32|0|144.64|3.2
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WORKER'S COMP [2125]|TML WC [212537]|190.32||||190.32|95.16|144.64|3.2
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|59.4||||59.4||45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|23.12|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|0.96|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|23.12|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
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]|59.4||||59.4|42.77|45.14|0.96
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]|59.4||||59.4|29.7|45.14|0.96
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]|59.4||||59.4|29.7|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|45.14|45.14|0.96
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]|59.4||||59.4|23.12|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4||45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|0.96|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|0|45.14|0.96
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]|59.4||||59.4|23.12|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|0|45.14|0.96
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]|59.4||||59.4|23.12|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|45.14|0.96
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]|59.4||||59.4|23.12|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|59.4||||59.4|11.88|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|59.4||||59.4|40.99|45.14|0.96
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]|59.4||||59.4|23.12|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4||45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|59.4||||59.4||45.14|0.96
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]|59.4||||59.4||45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
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]|59.4||||59.4|0|45.14|0.96
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4||45.14|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AARP [1000]|AARP [100000]|98.41||||98.41||74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AETNA [1015]|AETNA [101529]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMBETTER [2930]|AMBETTER [293000]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|98.41||||98.41|0.96|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|98.41||||98.41|38.3|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|70.86|74.79|0.96
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]|98.41||||98.41|49.21|74.79|0.96
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]|98.41||||98.41|49.21|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|98.41||||98.41|74.79|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|98.41||||98.41|67.9|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA [1260]|CIGNA PPO [126025]|98.41||||98.41|39.36|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|98.41||||98.41||74.79|0.96
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]|98.41||||98.41|67.9|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|98.41||||98.41|0.96|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|98.41||||98.41|67.9|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|98.41||||98.41|67.9|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|Self-pay|Self-pay|98.41||||98.41|19.68|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|TML [1980]|TML [198000]|98.41||||98.41|67.9|74.79|0.96
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]|98.41||||98.41|38.3|74.79|0.96
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]|98.41||||98.41||74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNICARE [2040]|UNICARE [204000]|98.41||||98.41||74.79|0.96
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]|98.41||||98.41||74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WEB TPA [2115]|WEB TPA [211500]|98.41||||98.41|67.9|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
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]|98.41||||98.41|0|74.79|0.96
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WORKER'S COMP [2125]|TML WC [212537]|98.41||||98.41||74.79|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|655.91||||655.91||498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|655.91||||655.91|255.28|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|655.91||||655.91|0.96|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|655.91||||655.91|255.28|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
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]|655.91||||655.91|472.26|498.49|0.96
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]|655.91||||655.91|327.96|498.49|0.96
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]|655.91||||655.91|327.96|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|655.91||||655.91|498.49|498.49|0.96
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]|655.91||||655.91|255.28|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|655.91||||655.91|452.58|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|655.91||||655.91|262.36|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|655.91||||655.91||498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|655.91||||655.91|452.58|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|655.91||||655.91|0.96|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|655.91||||655.91|452.58|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|655.91||||655.91|0|498.49|0.96
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]|655.91||||655.91|255.28|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|655.91||||655.91|0|498.49|0.96
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]|655.91||||655.91|255.28|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|655.91||||655.91|452.58|498.49|0.96
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]|655.91||||655.91|255.28|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|655.91||||655.91|131.18|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|655.91||||655.91|452.58|498.49|0.96
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]|655.91||||655.91|255.28|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|655.91||||655.91||498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|655.91||||655.91||498.49|0.96
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]|655.91||||655.91||498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|655.91||||655.91|452.58|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
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]|655.91||||655.91|0|498.49|0.96
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|655.91||||655.91||498.49|0.96
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AARP [1000]|AARP [100000]|82.5||||82.5|41.25|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82.5||||82.5|32.11|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|82.5||||82.5|0.51|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|82.5||||82.5|32.11|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
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]|82.5||||82.5|59.4|62.7|0.51
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]|82.5||||82.5|41.25|62.7|0.51
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]|82.5||||82.5|41.25|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|82.5||||82.5|62.7|62.7|0.51
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]|82.5||||82.5|32.11|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|82.5||||82.5|56.93|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|82.5||||82.5|33|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|82.5||||82.5|41.25|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|82.5||||82.5|56.93|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|82.5||||82.5|0.51|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|82.5||||82.5|56.93|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.5||||82.5|0|62.7|0.51
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]|82.5||||82.5|32.11|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82.5||||82.5|0|62.7|0.51
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]|82.5||||82.5|32.11|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|82.5||||82.5|56.93|62.7|0.51
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]|82.5||||82.5|32.11|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|Self-pay|Self-pay|82.5||||82.5|16.5|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|TML [1980]|TML [198000]|82.5||||82.5|56.93|62.7|0.51
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]|82.5||||82.5|32.11|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82.5||||82.5|41.25|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|82.5||||82.5|41.25|62.7|0.51
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]|82.5||||82.5|41.25|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|82.5||||82.5|56.93|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
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]|82.5||||82.5|0|62.7|0.51
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|82.5||||82.5|41.25|62.7|0.51
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AARP [1000]|AARP [100000]|65.64||||65.64||49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AETNA [1015]|AETNA [101529]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMBETTER [2930]|AMBETTER [293000]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|65.64||||65.64|32.82|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.64||||65.64|47.26|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.64||||65.64|32.82|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.64||||65.64|32.82|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|65.64||||65.64|49.89|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|CIGNA [1260]|CIGNA PPO [126025]|65.64||||65.64|26.26|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|65.64||||65.64||49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|GROUP PENSION ADMIN [1450]|GPA [145000]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|65.64||||65.64|32.82|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|PHCS [1780]|PHCS MULTIPLAN [178000]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|Self-pay|Self-pay|65.64||||65.64|13.13|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|TML [1980]|TML [198000]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.64||||65.64|25.55|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.64||||65.64||49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UNICARE [2040]|UNICARE [204000]|65.64||||65.64||49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.64||||65.64||49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WEB TPA [2115]|WEB TPA [211500]|65.64||||65.64|45.29|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.64||||65.64|0|49.89|13.13
91352|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT|113 g|WORKER'S COMP [2125]|TML WC [212537]|65.64||||65.64||49.89|13.13
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|3303.3||||3303.3|1651.65|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMBETTER [2930]|AMBETTER [293000]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3303.3||||3303.3|77.18|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3303.3||||3303.3|1285.64|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|2378.38|2510.51|77.18
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]|3303.3||||3303.3|1651.65|2510.51|77.18
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]|3303.3||||3303.3|1651.65|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3303.3||||3303.3|2510.51|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3303.3||||3303.3|2279.28|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA PPO [126025]|3303.3||||3303.3|1321.32|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3303.3||||3303.3|1651.65|2510.51|77.18
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]|3303.3||||3303.3|2279.28|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3303.3||||3303.3|77.18|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3303.3||||3303.3|2279.28|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3303.3||||3303.3|2279.28|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|3303.3||||3303.3|660.66|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|TML [1980]|TML [198000]|3303.3||||3303.3|2279.28|2510.51|77.18
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]|3303.3||||3303.3|1285.64|2510.51|77.18
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]|3303.3||||3303.3|1651.65|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNICARE [2040]|UNICARE [204000]|3303.3||||3303.3|1651.65|2510.51|77.18
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]|3303.3||||3303.3|1651.65|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WEB TPA [2115]|WEB TPA [211500]|3303.3||||3303.3|2279.28|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
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]|3303.3||||3303.3|0|2510.51|77.18
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TML WC [212537]|3303.3||||3303.3|1651.65|2510.51|77.18
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|81.65||||81.65||62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.65||||81.65|40.83|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.65||||81.65|31.78|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.65||||81.65|58.79|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.65||||81.65|40.83|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.65||||81.65|40.83|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.65||||81.65|62.05|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.65||||81.65|56.34|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|81.65||||81.65|32.66|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.65||||81.65||62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|81.65||||81.65|56.34|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.65||||81.65|40.83|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.65||||81.65|56.34|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.65||||81.65|0|62.05|16.33
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]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|81.65||||81.65|56.34|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|Self-pay|Self-pay|81.65||||81.65|16.33|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|81.65||||81.65|56.34|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.65||||81.65|31.78|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.65||||81.65||62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|81.65||||81.65||62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.65||||81.65||62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|81.65||||81.65|56.34|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.65||||81.65|0|62.05|16.33
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]|81.65||||81.65|0|62.05|16.33
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|81.65||||81.65||62.05|16.33
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AARP [1000]|AARP [100000]|1775.67||||1775.67||1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AETNA [1015]|AETNA [101529]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1775.67||||1775.67|887.84|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1775.67||||1775.67|1278.48|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1775.67||||1775.67|887.84|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1775.67||||1775.67|887.84|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1775.67||||1775.67|1349.51|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|1775.67||||1775.67|710.27|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1775.67||||1775.67||1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1775.67||||1775.67|887.84|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|Self-pay|Self-pay|1775.67||||1775.67|355.13|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|TML [1980]|TML [198000]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1775.67||||1775.67|691.09|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1775.67||||1775.67||1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UNICARE [2040]|UNICARE [204000]|1775.67||||1775.67||1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1775.67||||1775.67||1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|1775.67||||1775.67|1225.21|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1775.67||||1775.67|0|1349.51|355.13
91651|ERX|0250 - PHARMACY-GENERAL|METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|1775.67||||1775.67||1349.51|355.13
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.93||||8.93||6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|8.93||||8.93|1.27|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.93||||8.93|6.43|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.93||||8.93|4.47|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.93||||8.93|4.47|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|8.93||||8.93|6.79|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|8.93||||8.93|3.57|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|8.93||||8.93||6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|8.93||||8.93|1.27|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|8.93||||8.93|1.79|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.93||||8.93|3.48|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.93||||8.93||6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|8.93||||8.93||6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.93||||8.93||6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|8.93||||8.93|6.16|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.93||||8.93|0|6.79|1.27
9183|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZATHIOPRINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|8.93||||8.93||6.79|1.27
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|382.8||||382.8||290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|382.8||||382.8|191.4|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382.8||||382.8|275.62|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382.8||||382.8|191.4|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382.8||||382.8|191.4|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|382.8||||382.8|290.93|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|382.8||||382.8|153.12|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|382.8||||382.8||290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|382.8||||382.8|191.4|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|382.8||||382.8|76.56|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382.8||||382.8|148.99|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382.8||||382.8||290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|382.8||||382.8||290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382.8||||382.8||290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|382.8||||382.8|264.13|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382.8||||382.8|0|290.93|76.56
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|382.8||||382.8||290.93|76.56
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|765.6||||765.6||581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|765.6||||765.6|382.8|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|765.6||||765.6|551.23|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|765.6||||765.6|382.8|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|765.6||||765.6|382.8|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|765.6||||765.6|581.86|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|765.6||||765.6|306.24|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|765.6||||765.6||581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|765.6||||765.6|382.8|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|765.6||||765.6|153.12|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|765.6||||765.6|297.97|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|765.6||||765.6||581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|765.6||||765.6||581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|765.6||||765.6||581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|765.6||||765.6|528.26|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|765.6||||765.6|0|581.86|153.12
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|765.6||||765.6||581.86|153.12
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AARP [1000]|AARP [100000]|4540.8||||4540.8||3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AETNA [1015]|AETNA [101529]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AMBETTER [2930]|AMBETTER [293000]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4540.8||||4540.8|2270.4|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4540.8||||4540.8|3269.38|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4540.8||||4540.8|2270.4|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4540.8||||4540.8|2270.4|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4540.8||||4540.8|3451.01|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|CIGNA [1260]|CIGNA PPO [126025]|4540.8||||4540.8|1816.32|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4540.8||||4540.8||3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|GROUP PENSION ADMIN [1450]|GPA [145000]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4540.8||||4540.8|2270.4|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|PHCS [1780]|PHCS MULTIPLAN [178000]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|Self-pay|Self-pay|4540.8||||4540.8|908.16|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|TML [1980]|TML [198000]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4540.8||||4540.8|1767.28|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4540.8||||4540.8||3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|UNICARE [2040]|UNICARE [204000]|4540.8||||4540.8||3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4540.8||||4540.8||3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|WEB TPA [2115]|WEB TPA [211500]|4540.8||||4540.8|3133.15|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4540.8||||4540.8|0|3451.01|908.16
91965|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION|20,000 Units|WORKER'S COMP [2125]|TML WC [212537]|4540.8||||4540.8||3451.01|908.16
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AARP [1000]|AARP [100000]|3406||||3406|702|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AETNA [1015]|AETNA [101529]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AMBETTER [2930]|AMBETTER [293000]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3406||||3406|299.17|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3406||||3406|302.82|2588.56|299.17
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]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3406||||3406|2452.32|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3406||||3406|1703|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3406||||3406|1703|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3406||||3406|2588.56|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3406||||3406|2350.14|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA [1260]|CIGNA PPO [126025]|3406||||3406|500.15|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3406||||3406|702|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3406||||3406|2350.14|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3406||||3406|299.17|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3406||||3406|2350.14|2588.56|299.17
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]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3406||||3406|0|2588.56|299.17
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]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3406||||3406|2350.14|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|Self-pay|Self-pay|3406||||3406|681.2|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|TML [1980]|TML [198000]|3406||||3406|2350.14|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3406||||3406|302.82|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3406||||3406|702|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UNICARE [2040]|UNICARE [204000]|3406||||3406|702|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3406||||3406|702|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|WEB TPA [2115]|WEB TPA [211500]|3406||||3406|2350.14|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3406||||3406|0|2588.56|299.17
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]|3406||||3406|0|2588.56|299.17
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|WORKER'S COMP [2125]|TML WC [212537]|3406||||3406|702|2588.56|299.17
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AARP [1000]|AARP [100000]|1625.07||||1625.07|702|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AETNA [1015]|AETNA [101529]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AMBETTER [2930]|AMBETTER [293000]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1625.07||||1625.07|141.66|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1625.07||||1625.07|178.89|1235.05|141.66
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]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1625.07||||1625.07|1170.05|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1625.07||||1625.07|812.54|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1625.07||||1625.07|812.54|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1625.07||||1625.07|1235.05|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1625.07||||1625.07|1121.3|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA [1260]|CIGNA PPO [126025]|1625.07||||1625.07|500.15|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1625.07||||1625.07|702|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1625.07||||1625.07|1121.3|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1625.07||||1625.07|141.66|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1625.07||||1625.07|1121.3|1235.05|141.66
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]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1625.07||||1625.07|0|1235.05|141.66
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]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1625.07||||1625.07|1121.3|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|Self-pay|Self-pay|1625.07||||1625.07|325.01|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|TML [1980]|TML [198000]|1625.07||||1625.07|1121.3|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1625.07||||1625.07|178.89|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1625.07||||1625.07|702|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UNICARE [2040]|UNICARE [204000]|1625.07||||1625.07|702|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1625.07||||1625.07|702|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|WEB TPA [2115]|WEB TPA [211500]|1625.07||||1625.07|1121.3|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1625.07||||1625.07|0|1235.05|141.66
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]|1625.07||||1625.07|0|1235.05|141.66
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|WORKER'S COMP [2125]|TML WC [212537]|1625.07||||1625.07|702|1235.05|141.66
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AARP [1000]|AARP [100000]|3739||||3739|702|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AETNA [1015]|AETNA [101529]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMBETTER [2930]|AMBETTER [293000]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3739||||3739|299.17|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3739||||3739|2692.08|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3739||||3739|1869.5|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3739||||3739|1869.5|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3739||||3739|2841.64|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|CIGNA [1260]|CIGNA PPO [126025]|3739||||3739|500.15|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3739||||3739|702|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3739||||3739|299.17|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|Self-pay|Self-pay|3739||||3739|747.8|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|TML [1980]|TML [198000]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3739||||3739|366.59|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3739||||3739|702|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UNICARE [2040]|UNICARE [204000]|3739||||3739|702|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3739||||3739|702|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WEB TPA [2115]|WEB TPA [211500]|3739||||3739|2579.91|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3739||||3739|0|2841.64|299.17
92193886|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD INTRACRANIAL ART COMPLETE|1|WORKER'S COMP [2125]|TML WC [212537]|3739||||3739|702|2841.64|299.17
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AARP [1000]|AARP [100000]|2712||||2712|702|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AETNA [1015]|AETNA [101529]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMBETTER [2930]|AMBETTER [293000]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2712||||2712|141.66|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2712||||2712|1952.64|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2712||||2712|1356|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2712||||2712|1356|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2712||||2712|2061.12|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|CIGNA [1260]|CIGNA PPO [126025]|2712||||2712|1084.8|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2712||||2712|702|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2712||||2712|141.66|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|Self-pay|Self-pay|2712||||2712|542.4|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|TML [1980]|TML [198000]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2712||||2712|178.89|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2712||||2712|702|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UNICARE [2040]|UNICARE [204000]|2712||||2712|702|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2712||||2712|702|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WEB TPA [2115]|WEB TPA [211500]|2712||||2712|1871.28|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2712||||2712|0|2061.12|141.66
92193892|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMB DETECT W/O MICROBUBBLE|1|WORKER'S COMP [2125]|TML WC [212537]|2712||||2712|702|2061.12|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AARP [1000]|AARP [100000]|1885||||1885|702|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AETNA [1015]|AETNA [101529]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMBETTER [2930]|AMBETTER [293000]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1885||||1885|141.66|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1885||||1885|1357.2|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1885||||1885|942.5|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1885||||1885|942.5|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1885||||1885|1432.6|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|CIGNA [1260]|CIGNA PPO [126025]|1885||||1885|754|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1885||||1885|702|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1885||||1885|141.66|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|Self-pay|Self-pay|1885||||1885|377|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|TML [1980]|TML [198000]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1885||||1885|178.89|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1885||||1885|702|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UNICARE [2040]|UNICARE [204000]|1885||||1885|702|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1885||||1885|702|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WEB TPA [2115]|WEB TPA [211500]|1885||||1885|1300.65|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1885||||1885|0|1432.6|141.66
92193893|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US TCD EMBOL DETECT W/MICROBUBBLE|1|WORKER'S COMP [2125]|TML WC [212537]|1885||||1885|702|1432.6|141.66
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AARP [1000]|AARP [100000]|3852||||3852|702|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AETNA [1015]|AETNA [101529]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AMBETTER [2930]|AMBETTER [293000]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3852||||3852|181.42|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3852||||3852|200.82|2927.52|181.42
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]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3852||||3852|2773.44|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3852||||3852|1926|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3852||||3852|1926|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3852||||3852|2927.52|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3852||||3852|2657.88|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA [1260]|CIGNA PPO [126025]|3852||||3852|422.54|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3852||||3852|702|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3852||||3852|2657.88|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3852||||3852|181.42|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3852||||3852|2657.88|2927.52|181.42
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]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3852||||3852|0|2927.52|181.42
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]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3852||||3852|2657.88|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|Self-pay|Self-pay|3852||||3852|770.4|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|TML [1980]|TML [198000]|3852||||3852|2657.88|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3852||||3852|200.82|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3852||||3852|702|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UNICARE [2040]|UNICARE [204000]|3852||||3852|702|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3852||||3852|702|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|WEB TPA [2115]|WEB TPA [211500]|3852||||3852|2657.88|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3852||||3852|0|2927.52|181.42
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]|3852||||3852|0|2927.52|181.42
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|WORKER'S COMP [2125]|TML WC [212537]|3852||||3852|702|2927.52|181.42
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AARP [1000]|AARP [100000]|3987||||3987|702|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AETNA [1015]|AETNA [101529]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AMBETTER [2930]|AMBETTER [293000]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3987||||3987|299.17|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3987||||3987|309.19|3030.12|299.17
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]|3987||||3987|0|3030.12|299.17
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]|3987||||3987|2870.64|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3987||||3987|1993.5|3030.12|299.17
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]|3987||||3987|1993.5|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3987||||3987|3030.12|3030.12|299.17
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]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3987||||3987|2751.03|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA [1260]|CIGNA PPO [126025]|3987||||3987|500.15|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3987||||3987|702|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3987||||3987|2751.03|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3987||||3987|299.17|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3987||||3987|2751.03|3030.12|299.17
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]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3987||||3987|0|3030.12|299.17
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]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3987||||3987|2751.03|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|Self-pay|Self-pay|3987||||3987|797.4|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|TML [1980]|TML [198000]|3987||||3987|2751.03|3030.12|299.17
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]|3987||||3987|309.19|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3987||||3987|702|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UNICARE [2040]|UNICARE [204000]|3987||||3987|702|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3987||||3987|702|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|WEB TPA [2115]|WEB TPA [211500]|3987||||3987|2751.03|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3987||||3987|0|3030.12|299.17
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]|3987||||3987|0|3030.12|299.17
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|WORKER'S COMP [2125]|TML WC [212537]|3987||||3987|702|3030.12|299.17
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AARP [1000]|AARP [100000]|4889||||4889|702|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AETNA [1015]|AETNA [101529]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AMBETTER [2930]|AMBETTER [293000]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4889||||4889|299.17|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4889||||4889|3520.08|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4889||||4889|2444.5|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4889||||4889|2444.5|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4889||||4889|3715.64|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA [1260]|CIGNA PPO [126025]|4889||||4889|500.15|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4889||||4889|702|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4889||||4889|299.17|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|Self-pay|Self-pay|4889||||4889|977.8|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|TML [1980]|TML [198000]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4889||||4889|293.26|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4889||||4889|702|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UNICARE [2040]|UNICARE [204000]|4889||||4889|702|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4889||||4889|702|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|WEB TPA [2115]|WEB TPA [211500]|4889||||4889|3373.41|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4889||||4889|0|3715.64|293.26
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]|4889||||4889|0|3715.64|293.26
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|WORKER'S COMP [2125]|TML WC [212537]|4889||||4889|702|3715.64|293.26
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AARP [1000]|AARP [100000]|2948||||2948|702|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AETNA [1015]|AETNA [101529]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AMBETTER [2930]|AMBETTER [293000]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2948||||2948|141.66|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2948||||2948|2122.56|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2948||||2948|1474|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2948||||2948|1474|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2948||||2948|2240.48|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA [1260]|CIGNA PPO [126025]|2948||||2948|500.15|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2948||||2948|702|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2948||||2948|141.66|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|Self-pay|Self-pay|2948||||2948|589.6|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|TML [1980]|TML [198000]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2948||||2948|178.89|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2948||||2948|702|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UNICARE [2040]|UNICARE [204000]|2948||||2948|702|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2948||||2948|702|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|WEB TPA [2115]|WEB TPA [211500]|2948||||2948|2034.12|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2948||||2948|0|2240.48|141.66
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]|2948||||2948|0|2240.48|141.66
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|WORKER'S COMP [2125]|TML WC [212537]|2948||||2948|702|2240.48|141.66
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AARP [1000]|AARP [100000]|930.25||||930.25|702|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AETNA [1015]|AETNA [101529]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AMBETTER [2930]|AMBETTER [293000]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|930.25||||930.25|145.54|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|930.25||||930.25|669.78|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|930.25||||930.25|465.13|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|930.25||||930.25|465.13|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|930.25||||930.25|706.99|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|CIGNA [1260]|CIGNA PPO [126025]|930.25||||930.25|372.1|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|930.25||||930.25|702|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|930.25||||930.25|145.54|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|Self-pay|Self-pay|930.25||||930.25|186.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|TML [1980]|TML [198000]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|930.25||||930.25|362.05|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|930.25||||930.25|702|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|UNICARE [2040]|UNICARE [204000]|930.25||||930.25|702|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|930.25||||930.25|702|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|WEB TPA [2115]|WEB TPA [211500]|930.25||||930.25|641.87|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|930.25||||930.25|0|706.99|145.54
92295860|EAP|0922 - OTHER DIAGNOSTIC SERVICES-ELECTROMYOGRAM|HC EMG ONE EXTREMITY|1|WORKER'S COMP [2125]|TML WC [212537]|930.25||||930.25|702|706.99|145.54
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|620.4||||620.4||471.5|22.31
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]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|620.4||||620.4|241.46|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|620.4||||620.4|22.31|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|620.4||||620.4|241.46|471.5|22.31
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]|620.4||||620.4|0|471.5|22.31
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]|620.4||||620.4|446.69|471.5|22.31
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]|620.4||||620.4|310.2|471.5|22.31
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]|620.4||||620.4|310.2|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|620.4||||620.4|471.5|471.5|22.31
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]|620.4||||620.4|241.46|471.5|22.31
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]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|620.4||||620.4|428.08|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|620.4||||620.4|248.16|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|620.4||||620.4||471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|620.4||||620.4|428.08|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|620.4||||620.4|22.31|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|620.4||||620.4|428.08|471.5|22.31
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]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|620.4||||620.4|241.46|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|620.4||||620.4|0|471.5|22.31
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]|620.4||||620.4|241.46|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|620.4||||620.4|428.08|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|620.4||||620.4|241.46|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|620.4||||620.4|124.08|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|620.4||||620.4|428.08|471.5|22.31
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]|620.4||||620.4|241.46|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|620.4||||620.4||471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|620.4||||620.4||471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|620.4||||620.4||471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|620.4||||620.4|428.08|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|620.4||||620.4|0|471.5|22.31
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]|620.4||||620.4|0|471.5|22.31
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|620.4||||620.4||471.5|22.31
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AARP [1000]|AARP [100000]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AETNA [1015]|AETNA [101529]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AMBETTER [2930]|AMBETTER [293000]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|652.61||||652.61|9.37|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|652.61||||652.61|469.88|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|652.61||||652.61|495.98|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|CIGNA [1260]|CIGNA PPO [126025]|652.61||||652.61|261.04|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|652.61||||652.61|9.37|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|Self-pay|Self-pay|652.61||||652.61|130.52|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|TML [1980]|TML [198000]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|652.61||||652.61|254|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|UNICARE [2040]|UNICARE [204000]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|652.61||||652.61|326.31|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|WEB TPA [2115]|WEB TPA [211500]|652.61||||652.61|450.3|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|652.61||||652.61|0|495.98|9.37
9266|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION|5 mL|WORKER'S COMP [2125]|TML WC [212537]|652.61||||652.61|326.31|495.98|9.37
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AARP [1000]|AARP [100000]|31680||||31680||24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AETNA [1015]|AETNA [101529]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AMBETTER [2930]|AMBETTER [293000]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|31680||||31680|2.94|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31680||||31680|22809.6|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31680||||31680|15840|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31680||||31680|15840|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|31680||||31680|24076.8|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|CIGNA [1260]|CIGNA PPO [126025]|31680||||31680|15840|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|31680||||31680||24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|31680||||31680|2.94|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|Self-pay|Self-pay|31680||||31680|6336|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|TML [1980]|TML [198000]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31680||||31680|12329.86|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31680||||31680||24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|UNICARE [2040]|UNICARE [204000]|31680||||31680||24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31680||||31680||24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|WEB TPA [2115]|WEB TPA [211500]|31680||||31680|21859.2|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31680||||31680|0|24076.8|2.94
92853|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION|1 mg|WORKER'S COMP [2125]|TML WC [212537]|31680||||31680||24076.8|2.94
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|27.88||||27.88||21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMBETTER [2930]|AMBETTER [293000]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.88||||27.88|13.94|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.88||||27.88|20.07|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.88||||27.88|13.94|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.88||||27.88|13.94|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.88||||27.88|21.19|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA PPO [126025]|27.88||||27.88|11.15|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.88||||27.88||21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.88||||27.88|13.94|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|27.88||||27.88|5.58|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|TML [1980]|TML [198000]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.88||||27.88|10.85|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.88||||27.88||21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNICARE [2040]|UNICARE [204000]|27.88||||27.88||21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.88||||27.88||21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WEB TPA [2115]|WEB TPA [211500]|27.88||||27.88|19.24|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.88||||27.88|0|21.19|5.58
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]|27.88||||27.88|0|21.19|5.58
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TML WC [212537]|27.88||||27.88||21.19|5.58
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|20.32||||20.32|10.16|15.44|4.06
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]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMBETTER [2930]|AMBETTER [293000]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.32||||20.32|7.91|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|20.32||||20.32|7.91|15.44|4.06
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]|20.32||||20.32|0|15.44|4.06
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]|20.32||||20.32|14.63|15.44|4.06
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]|20.32||||20.32|10.16|15.44|4.06
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]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|20.32||||20.32|15.44|15.44|4.06
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]|20.32||||20.32|7.91|15.44|4.06
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]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|20.32||||20.32|14.02|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA PPO [126025]|20.32||||20.32|8.13|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20.32||||20.32|14.02|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|20.32||||20.32|14.02|15.44|4.06
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]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.32||||20.32|7.91|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.32||||20.32|0|15.44|4.06
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]|20.32||||20.32|7.91|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.32||||20.32|14.02|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.32||||20.32|7.91|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|20.32||||20.32|4.06|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|TML [1980]|TML [198000]|20.32||||20.32|14.02|15.44|4.06
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]|20.32||||20.32|7.91|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNICARE [2040]|UNICARE [204000]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.32||||20.32|10.16|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WEB TPA [2115]|WEB TPA [211500]|20.32||||20.32|14.02|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.32||||20.32|0|15.44|4.06
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]|20.32||||20.32|0|15.44|4.06
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TML WC [212537]|20.32||||20.32|10.16|15.44|4.06
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.44||||11.44||8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.44||||11.44|5.72|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.44||||11.44|4.45|8.69|2.29
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]|11.44||||11.44|0|8.69|2.29
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]|11.44||||11.44|8.24|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.44||||11.44|5.72|8.69|2.29
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]|11.44||||11.44|5.72|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.44||||11.44|8.69|8.69|2.29
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]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.44||||11.44|7.89|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.44||||11.44|4.58|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.44||||11.44||8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.44||||11.44|7.89|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.44||||11.44|5.72|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.44||||11.44|7.89|8.69|2.29
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]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.44||||11.44|0|8.69|2.29
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]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.44||||11.44|7.89|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|11.44||||11.44|2.29|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.44||||11.44|7.89|8.69|2.29
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]|11.44||||11.44|4.45|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.44||||11.44||8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.44||||11.44||8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.44||||11.44||8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.44||||11.44|7.89|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.44||||11.44|0|8.69|2.29
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]|11.44||||11.44|0|8.69|2.29
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.44||||11.44||8.69|2.29
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.53||||11.53||8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|11.53||||11.53|5.77|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|11.53||||11.53|4.49|8.76|2.31
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]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.53||||11.53|8.3|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.53||||11.53|5.77|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.53||||11.53|5.77|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|11.53||||11.53|8.76|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|11.53||||11.53|7.96|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|11.53||||11.53|4.61|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|11.53||||11.53||8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.53||||11.53|7.96|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|11.53||||11.53|5.77|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|11.53||||11.53|7.96|8.76|2.31
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]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.53||||11.53|0|8.76|2.31
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]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.53||||11.53|7.96|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|Self-pay|Self-pay|11.53||||11.53|2.31|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|11.53||||11.53|7.96|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.53||||11.53|4.49|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.53||||11.53||8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|11.53||||11.53||8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.53||||11.53||8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|11.53||||11.53|7.96|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.53||||11.53|0|8.76|2.31
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]|11.53||||11.53|0|8.76|2.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|11.53||||11.53||8.76|2.31
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.52||||9.52||7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.52||||9.52|4.76|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.52||||9.52|6.85|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.52||||9.52|4.76|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.52||||9.52|4.76|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.52||||9.52|7.24|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|9.52||||9.52|3.81|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.52||||9.52||7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.52||||9.52|4.76|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|Self-pay|Self-pay|9.52||||9.52|1.9|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.52||||9.52|3.71|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.52||||9.52||7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|9.52||||9.52||7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.52||||9.52||7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|9.52||||9.52|6.57|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.52||||9.52|0|7.24|1.9
9321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|9.52||||9.52||7.24|1.9
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.15||||7.15||5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|7.15||||7.15|3.58|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|7.15||||7.15|2.78|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
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]|7.15||||7.15|5.15|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.15||||7.15|3.58|5.43|1.43
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]|7.15||||7.15|3.58|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|7.15||||7.15|5.43|5.43|1.43
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]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|7.15||||7.15|4.93|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|7.15||||7.15|2.86|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|7.15||||7.15||5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.15||||7.15|4.93|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|7.15||||7.15|3.58|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|7.15||||7.15|4.93|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.15||||7.15|0|5.43|1.43
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]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.15||||7.15|4.93|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|Self-pay|Self-pay|7.15||||7.15|1.43|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|TML [1980]|TML [198000]|7.15||||7.15|4.93|5.43|1.43
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]|7.15||||7.15|2.78|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.15||||7.15||5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|7.15||||7.15||5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.15||||7.15||5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|7.15||||7.15|4.93|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.15||||7.15|0|5.43|1.43
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]|7.15||||7.15|0|5.43|1.43
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|7.15||||7.15||5.43|1.43
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.34||||1.34||1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.34||||1.34|0.67|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.34||||1.34|0.52|1.02|0.27
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]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.34||||1.34|0.96|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.34||||1.34|0.67|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.34||||1.34|0.67|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.34||||1.34|1.02|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.34||||1.34|0.92|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.34||||1.34|0.54|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.34||||1.34||1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.34||||1.34|0.92|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.34||||1.34|0.67|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.34||||1.34|0.92|1.02|0.27
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]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.34||||1.34|0|1.02|0.27
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]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.34||||1.34|0.92|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.34||||1.34|0.27|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.34||||1.34|0.92|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.34||||1.34|0.52|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.34||||1.34||1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.34||||1.34||1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.34||||1.34||1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.34||||1.34|0.92|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.34||||1.34|0|1.02|0.27
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]|1.34||||1.34|0|1.02|0.27
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.34||||1.34||1.02|0.27
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|30.1|3.85
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]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|3.85|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|3.85
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]|39.6||||39.6|0|30.1|3.85
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]|39.6||||39.6|28.51|30.1|3.85
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]|39.6||||39.6|19.8|30.1|3.85
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]|39.6||||39.6|19.8|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|3.85
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]|39.6||||39.6|15.41|30.1|3.85
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]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|3.85|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|3.85
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]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|3.85
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]|39.6||||39.6|15.41|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|3.85
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]|39.6||||39.6|15.41|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|19.8|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|19.8|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|3.85
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]|39.6||||39.6|0|30.1|3.85
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|30.1|3.85
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|41343.72||||41343.72||31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AMBETTER [2930]|AMBETTER [293000]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41343.72||||41343.72|16090.98|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41343.72||||41343.72|3679.72|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41343.72||||41343.72|16090.98|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
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]|41343.72||||41343.72|29767.48|31421.23|3679.72
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]|41343.72||||41343.72|20671.86|31421.23|3679.72
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]|41343.72||||41343.72|20671.86|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41343.72||||41343.72|31421.23|31421.23|3679.72
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]|41343.72||||41343.72|16090.98|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41343.72||||41343.72|28527.17|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA PPO [126025]|41343.72||||41343.72|20671.86|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41343.72||||41343.72||31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41343.72||||41343.72|28527.17|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41343.72||||41343.72|3679.72|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41343.72||||41343.72|28527.17|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41343.72||||41343.72|0|31421.23|3679.72
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]|41343.72||||41343.72|16090.98|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41343.72||||41343.72|0|31421.23|3679.72
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]|41343.72||||41343.72|16090.98|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41343.72||||41343.72|28527.17|31421.23|3679.72
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]|41343.72||||41343.72|16090.98|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|41343.72||||41343.72|8268.74|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|TML [1980]|TML [198000]|41343.72||||41343.72|28527.17|31421.23|3679.72
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]|41343.72||||41343.72|16090.98|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41343.72||||41343.72||31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UNICARE [2040]|UNICARE [204000]|41343.72||||41343.72||31421.23|3679.72
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]|41343.72||||41343.72||31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|WEB TPA [2115]|WEB TPA [211500]|41343.72||||41343.72|28527.17|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
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]|41343.72||||41343.72|0|31421.23|3679.72
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TML WC [212537]|41343.72||||41343.72||31421.23|3679.72
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|12.49||||12.49||9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.49||||12.49|6.25|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.49||||12.49|4.86|9.49|2.5
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]|12.49||||12.49|0|9.49|2.5
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]|12.49||||12.49|8.99|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.49||||12.49|6.25|9.49|2.5
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]|12.49||||12.49|6.25|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.49||||12.49|9.49|9.49|2.5
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]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.49||||12.49|8.62|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|12.49||||12.49|5|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.49||||12.49||9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.49||||12.49|8.62|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.49||||12.49|6.25|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.49||||12.49|8.62|9.49|2.5
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]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.49||||12.49|0|9.49|2.5
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]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.49||||12.49|8.62|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|Self-pay|Self-pay|12.49||||12.49|2.5|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|TML [1980]|TML [198000]|12.49||||12.49|8.62|9.49|2.5
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]|12.49||||12.49|4.86|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.49||||12.49||9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|12.49||||12.49||9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.49||||12.49||9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|12.49||||12.49|8.62|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.49||||12.49|0|9.49|2.5
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]|12.49||||12.49|0|9.49|2.5
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|12.49||||12.49||9.49|2.5
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|0.55||||0.55||0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|0.55||||0.55|0.28|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0.4|0.42|0.11
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]|0.55||||0.55|0.28|0.42|0.11
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]|0.55||||0.55|0.28|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|0.55||||0.55|0.42|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|0.55||||0.55|0.38|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|0.55||||0.55|0.22|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|0.55||||0.55||0.42|0.11
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]|0.55||||0.55|0.38|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|0.55||||0.55|0.28|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|0.55||||0.55|0.38|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55|0.38|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|0.55||||0.55|0.11|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|TML [1980]|TML [198000]|0.55||||0.55|0.38|0.42|0.11
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]|0.55||||0.55|0.21|0.42|0.11
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]|0.55||||0.55||0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|0.55||||0.55||0.42|0.11
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]|0.55||||0.55||0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|0.55||||0.55|0.38|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
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]|0.55||||0.55|0|0.42|0.11
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|0.55||||0.55||0.42|0.11
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AARP [1000]|AARP [100000]|6.62||||6.62||5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AETNA [1015]|AETNA [101529]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMBETTER [2930]|AMBETTER [293000]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.62||||6.62|2.58|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6.62||||6.62|3.31|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6.62||||6.62|2.58|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
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]|6.62||||6.62|4.77|5.03|1.32
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]|6.62||||6.62|3.31|5.03|1.32
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]|6.62||||6.62|3.31|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6.62||||6.62|5.03|5.03|1.32
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]|6.62||||6.62|2.58|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6.62||||6.62|4.57|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA [1260]|CIGNA PPO [126025]|6.62||||6.62|2.65|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6.62||||6.62||5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.62||||6.62|4.57|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6.62||||6.62|3.31|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6.62||||6.62|4.57|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.62||||6.62|0|5.03|1.32
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]|6.62||||6.62|2.58|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.62||||6.62|0|5.03|1.32
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]|6.62||||6.62|2.58|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.62||||6.62|4.57|5.03|1.32
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]|6.62||||6.62|2.58|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|Self-pay|Self-pay|6.62||||6.62|1.32|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|TML [1980]|TML [198000]|6.62||||6.62|4.57|5.03|1.32
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]|6.62||||6.62|2.58|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.62||||6.62||5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNICARE [2040]|UNICARE [204000]|6.62||||6.62||5.03|1.32
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]|6.62||||6.62||5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WEB TPA [2115]|WEB TPA [211500]|6.62||||6.62|4.57|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
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]|6.62||||6.62|0|5.03|1.32
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WORKER'S COMP [2125]|TML WC [212537]|6.62||||6.62||5.03|1.32
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|18.68||||18.68||14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|18.68||||18.68|9.34|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|18.68||||18.68|7.27|14.2|3.74
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]|18.68||||18.68|0|14.2|3.74
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]|18.68||||18.68|13.45|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.68||||18.68|9.34|14.2|3.74
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]|18.68||||18.68|9.34|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|18.68||||18.68|14.2|14.2|3.74
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]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|18.68||||18.68|12.89|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|18.68||||18.68|7.47|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|18.68||||18.68||14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.68||||18.68|12.89|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|18.68||||18.68|9.34|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|18.68||||18.68|12.89|14.2|3.74
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]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.68||||18.68|0|14.2|3.74
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]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.68||||18.68|12.89|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|18.68||||18.68|3.74|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|TML [1980]|TML [198000]|18.68||||18.68|12.89|14.2|3.74
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]|18.68||||18.68|7.27|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.68||||18.68||14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|18.68||||18.68||14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.68||||18.68||14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|18.68||||18.68|12.89|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.68||||18.68|0|14.2|3.74
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]|18.68||||18.68|0|14.2|3.74
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|18.68||||18.68||14.2|3.74
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.82||||4.82||3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.82||||4.82|1.88|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4.82||||4.82|2.41|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4.82||||4.82|1.88|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
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]|4.82||||4.82|3.47|3.66|0.96
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]|4.82||||4.82|2.41|3.66|0.96
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]|4.82||||4.82|2.41|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4.82||||4.82|3.66|3.66|0.96
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]|4.82||||4.82|1.88|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4.82||||4.82|3.33|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|4.82||||4.82|1.93|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4.82||||4.82||3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.82||||4.82|3.33|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4.82||||4.82|2.41|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4.82||||4.82|3.33|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.82||||4.82|0|3.66|0.96
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]|4.82||||4.82|1.88|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.82||||4.82|0|3.66|0.96
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]|4.82||||4.82|1.88|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.82||||4.82|3.33|3.66|0.96
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]|4.82||||4.82|1.88|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.82||||4.82|0.96|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|4.82||||4.82|3.33|3.66|0.96
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]|4.82||||4.82|1.88|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.82||||4.82||3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|4.82||||4.82||3.66|0.96
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]|4.82||||4.82||3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|4.82||||4.82|3.33|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
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]|4.82||||4.82|0|3.66|0.96
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|4.82||||4.82||3.66|0.96
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AARP [1000]|AARP [100000]|1.18||||1.18||0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AETNA [1015]|AETNA [101529]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMBETTER [2930]|AMBETTER [293000]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.18||||1.18|0.59|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.18||||1.18|0.46|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0.85|0.9|0.24
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]|1.18||||1.18|0.59|0.9|0.24
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]|1.18||||1.18|0.59|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.18||||1.18|0.9|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.18||||1.18|0.81|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA PPO [126025]|1.18||||1.18|0.47|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.18||||1.18||0.9|0.24
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]|1.18||||1.18|0.81|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.18||||1.18|0.59|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.18||||1.18|0.81|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|Self-pay|Self-pay|1.18||||1.18|0.24|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|TML [1980]|TML [198000]|1.18||||1.18|0.81|0.9|0.24
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]|1.18||||1.18|0.46|0.9|0.24
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]|1.18||||1.18||0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNICARE [2040]|UNICARE [204000]|1.18||||1.18||0.9|0.24
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]|1.18||||1.18||0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WEB TPA [2115]|WEB TPA [211500]|1.18||||1.18|0.81|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
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]|1.18||||1.18|0|0.9|0.24
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WORKER'S COMP [2125]|TML WC [212537]|1.18||||1.18||0.9|0.24
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AARP [1000]|AARP [100000]|1341.12||||1341.12||1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AETNA [1015]|AETNA [101529]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AMBETTER [2930]|AMBETTER [293000]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1341.12||||1341.12|670.56|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1341.12||||1341.12|965.61|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1341.12||||1341.12|670.56|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1341.12||||1341.12|670.56|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1341.12||||1341.12|1019.25|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|CIGNA [1260]|CIGNA PPO [126025]|1341.12||||1341.12|536.45|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1341.12||||1341.12||1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1341.12||||1341.12|670.56|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|Self-pay|Self-pay|1341.12||||1341.12|268.22|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|TML [1980]|TML [198000]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1341.12||||1341.12|521.96|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1341.12||||1341.12||1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|UNICARE [2040]|UNICARE [204000]|1341.12||||1341.12||1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1341.12||||1341.12||1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|WEB TPA [2115]|WEB TPA [211500]|1341.12||||1341.12|925.37|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1341.12||||1341.12|0|1019.25|268.22
94219|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN|200 mL|WORKER'S COMP [2125]|TML WC [212537]|1341.12||||1341.12||1019.25|268.22
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AARP [1000]|AARP [100000]|97.36||||97.36|95|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|97.36||||97.36|48.68|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|97.36||||97.36|37.89|95|19.47
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]|97.36||||97.36|0|95|19.47
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]|97.36||||97.36|70.1|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.36||||97.36|48.68|95|19.47
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]|97.36||||97.36|48.68|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|97.36||||97.36|73.99|95|19.47
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]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|97.36||||97.36|67.18|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|97.36||||97.36|38.94|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|97.36||||97.36|95|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97.36||||97.36|67.18|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|97.36||||97.36|48.68|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|97.36||||97.36|67.18|95|19.47
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]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.36||||97.36|0|95|19.47
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]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97.36||||97.36|67.18|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|Self-pay|Self-pay|97.36||||97.36|19.47|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|TML [1980]|TML [198000]|97.36||||97.36|67.18|95|19.47
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]|97.36||||97.36|37.89|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.36||||97.36|95|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNICARE [2040]|UNICARE [204000]|97.36||||97.36|95|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.36||||97.36|95|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|97.36||||97.36|67.18|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.36||||97.36|0|95|19.47
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]|97.36||||97.36|0|95|19.47
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|97.36||||97.36|95|95|19.47
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AARP [1000]|AARP [100000]|94||||94|94|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMBETTER [2930]|AMBETTER [293000]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|94||||94|47|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|94||||94|36.58|94|18.8
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]|94||||94|0|94|18.8
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]|94||||94|67.68|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|94|18.8
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]|94||||94|47|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|94||||94|71.44|94|18.8
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]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|94||||94|64.86|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA [1260]|CIGNA PPO [126025]|94||||94|37.6|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|94||||94|94|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|94||||94|47|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|94||||94|64.86|94|18.8
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]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|0|94|18.8
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]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|Self-pay|Self-pay|94||||94|18.8|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|TML [1980]|TML [198000]|94||||94|64.86|94|18.8
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]|94||||94|36.58|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94|94|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNICARE [2040]|UNICARE [204000]|94||||94|94|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94|94|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WEB TPA [2115]|WEB TPA [211500]|94||||94|64.86|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94|0|94|18.8
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]|94||||94|0|94|18.8
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WORKER'S COMP [2125]|TML WC [212537]|94||||94|94|94|18.8
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AARP [1000]|AARP [100000]|320.4||||320.4|134|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AETNA [1015]|AETNA [101529]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMBETTER [2930]|AMBETTER [293000]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|320.4||||320.4|150.88|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|320.4||||320.4|230.69|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|320.4||||320.4|160.2|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|320.4||||320.4|160.2|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|320.4||||320.4|243.5|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|CIGNA [1260]|CIGNA PPO [126025]|320.4||||320.4|128.16|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|320.4||||320.4|134|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|320.4||||320.4|150.88|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|Self-pay|Self-pay|320.4||||320.4|64.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|TML [1980]|TML [198000]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|320.4||||320.4|124.7|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320.4||||320.4|134|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UNICARE [2040]|UNICARE [204000]|320.4||||320.4|134|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|320.4||||320.4|134|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WEB TPA [2115]|WEB TPA [211500]|320.4||||320.4|221.08|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|320.4||||320.4|0|243.5|64.08
94393797|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARD REHAB WO CONT ECG / SESSION|1|WORKER'S COMP [2125]|TML WC [212537]|320.4||||320.4|134|243.5|64.08
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AARP [1000]|AARP [100000]|641||||641|134|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AETNA [1015]|AETNA [101529]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMBETTER [2930]|AMBETTER [293000]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|641||||641|150.88|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|641||||641|461.52|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|641||||641|320.5|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|641||||641|320.5|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|641||||641|487.16|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA [1260]|CIGNA - GREAT WEST [126009]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|CIGNA [1260]|CIGNA PPO [126025]|641||||641|256.4|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|641||||641|134|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|641||||641|150.88|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|Self-pay|Self-pay|641||||641|128.2|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|TML [1980]|TML [198000]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|641||||641|249.48|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|641||||641|134|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UNICARE [2040]|UNICARE [204000]|641||||641|134|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|641||||641|134|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WEB TPA [2115]|WEB TPA [211500]|641||||641|442.29|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|641||||641|0|487.16|128.2
94393798|EAP|0943 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC CARDIAC REHAB WITH EKG MONITORING|1|WORKER'S COMP [2125]|TML WC [212537]|641||||641|134|487.16|128.2
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMBETTER [2930]|AMBETTER [293000]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131.34||||131.34|8.83|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131.34||||131.34|51.12|99.82|8.83
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]|131.34||||131.34|0|99.82|8.83
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]|131.34||||131.34|94.56|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131.34||||131.34|65.67|99.82|8.83
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]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131.34||||131.34|99.82|99.82|8.83
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]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131.34||||131.34|90.62|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|131.34||||131.34|52.54|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|131.34||||131.34|90.62|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131.34||||131.34|8.83|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131.34||||131.34|90.62|99.82|8.83
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]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131.34||||131.34|0|99.82|8.83
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]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|131.34||||131.34|90.62|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|131.34||||131.34|26.27|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|TML [1980]|TML [198000]|131.34||||131.34|90.62|99.82|8.83
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]|131.34||||131.34|51.12|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNICARE [2040]|UNICARE [204000]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131.34||||131.34|65.67|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WEB TPA [2115]|WEB TPA [211500]|131.34||||131.34|90.62|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131.34||||131.34|0|99.82|8.83
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]|131.34||||131.34|0|99.82|8.83
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|131.34||||131.34|65.67|99.82|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AARP [1000]|AARP [100000]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA [1015]|AETNA [101529]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMBETTER [2930]|AMBETTER [293000]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|168.3||||168.3|8.83|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|168.3||||168.3|65.5|127.91|8.83
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]|168.3||||168.3|0|127.91|8.83
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]|168.3||||168.3|121.18|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168.3||||168.3|84.15|127.91|8.83
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]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|168.3||||168.3|127.91|127.91|8.83
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]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|168.3||||168.3|116.13|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|168.3||||168.3|67.32|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|168.3||||168.3|116.13|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|168.3||||168.3|8.83|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|168.3||||168.3|116.13|127.91|8.83
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]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168.3||||168.3|0|127.91|8.83
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]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|168.3||||168.3|116.13|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|Self-pay|Self-pay|168.3||||168.3|33.66|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|TML [1980]|TML [198000]|168.3||||168.3|116.13|127.91|8.83
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]|168.3||||168.3|65.5|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNICARE [2040]|UNICARE [204000]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168.3||||168.3|84.15|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WEB TPA [2115]|WEB TPA [211500]|168.3||||168.3|116.13|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168.3||||168.3|0|127.91|8.83
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]|168.3||||168.3|0|127.91|8.83
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|168.3||||168.3|84.15|127.91|8.83
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|59.4||||59.4|29.7|45.14|2.57
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]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.4||||59.4|23.12|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|59.4||||59.4|2.57|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|59.4||||59.4|23.12|45.14|2.57
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]|59.4||||59.4|0|45.14|2.57
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]|59.4||||59.4|42.77|45.14|2.57
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]|59.4||||59.4|29.7|45.14|2.57
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]|59.4||||59.4|29.7|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|59.4||||59.4|45.14|45.14|2.57
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]|59.4||||59.4|23.12|45.14|2.57
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]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|59.4||||59.4|40.99|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|59.4||||59.4|23.76|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|59.4||||59.4|29.7|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|59.4||||59.4|40.99|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|59.4||||59.4|2.57|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|59.4||||59.4|40.99|45.14|2.57
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]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.4||||59.4|23.12|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.4||||59.4|0|45.14|2.57
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]|59.4||||59.4|23.12|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|59.4||||59.4|40.99|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.4||||59.4|23.12|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|59.4||||59.4|11.88|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|59.4||||59.4|40.99|45.14|2.57
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]|59.4||||59.4|23.12|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.4||||59.4|29.7|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|59.4||||59.4|29.7|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.4||||59.4|29.7|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|59.4||||59.4|40.99|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.4||||59.4|0|45.14|2.57
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]|59.4||||59.4|0|45.14|2.57
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|59.4||||59.4|29.7|45.14|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|132||||132|66|100.32|2.57
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]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|51.37|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|132||||132|2.57|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|132||||132|51.37|100.32|2.57
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]|132||||132|0|100.32|2.57
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]|132||||132|95.04|100.32|2.57
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]|132||||132|66|100.32|2.57
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]|132||||132|66|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|132||||132|100.32|100.32|2.57
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]|132||||132|51.37|100.32|2.57
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]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|132||||132|91.08|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|132||||132|52.8|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|132||||132|66|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|132||||132|2.57|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|132||||132|91.08|100.32|2.57
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]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|51.37|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|0|100.32|2.57
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]|132||||132|51.37|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|51.37|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|132||||132|26.4|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|132||||132|91.08|100.32|2.57
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]|132||||132|51.37|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|66|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|132||||132|66|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|66|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|132||||132|91.08|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132|0|100.32|2.57
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]|132||||132|0|100.32|2.57
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|132||||132|66|100.32|2.57
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|31.68||||31.68|15.84|24.08|0.73
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]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMBETTER [2930]|AMBETTER [293000]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.68||||31.68|12.33|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|31.68||||31.68|0.73|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|31.68||||31.68|12.33|24.08|0.73
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]|31.68||||31.68|0|24.08|0.73
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]|31.68||||31.68|22.81|24.08|0.73
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]|31.68||||31.68|15.84|24.08|0.73
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]|31.68||||31.68|15.84|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|31.68||||31.68|24.08|24.08|0.73
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]|31.68||||31.68|12.33|24.08|0.73
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]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|31.68||||31.68|21.86|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA PPO [126025]|31.68||||31.68|12.67|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|31.68||||31.68|15.84|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|31.68||||31.68|21.86|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|31.68||||31.68|0.73|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|31.68||||31.68|21.86|24.08|0.73
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]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.68||||31.68|12.33|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.68||||31.68|0|24.08|0.73
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]|31.68||||31.68|12.33|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|31.68||||31.68|21.86|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.68||||31.68|12.33|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|31.68||||31.68|6.34|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|TML [1980]|TML [198000]|31.68||||31.68|21.86|24.08|0.73
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]|31.68||||31.68|12.33|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.68||||31.68|15.84|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNICARE [2040]|UNICARE [204000]|31.68||||31.68|15.84|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.68||||31.68|15.84|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WEB TPA [2115]|WEB TPA [211500]|31.68||||31.68|21.86|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.68||||31.68|0|24.08|0.73
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]|31.68||||31.68|0|24.08|0.73
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TML WC [212537]|31.68||||31.68|15.84|24.08|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|37.81||||37.81|0.73|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.81||||37.81|27.22|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|37.81||||37.81|28.74|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|37.81||||37.81|15.12|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|37.81||||37.81|0.73|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|37.81||||37.81|7.56|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.81||||37.81|14.72|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.81||||37.81|18.91|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|37.81||||37.81|26.09|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.81||||37.81|0|28.74|0.73
9488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|37.81||||37.81|18.91|28.74|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AARP [1000]|AARP [100000]|9.96||||9.96|4.98|7.57|0.73
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]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AETNA [1015]|AETNA [101529]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AMBETTER [2930]|AMBETTER [293000]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.96||||9.96|3.88|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|9.96||||9.96|0.73|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|9.96||||9.96|3.88|7.57|0.73
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]|9.96||||9.96|0|7.57|0.73
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]|9.96||||9.96|7.17|7.57|0.73
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]|9.96||||9.96|4.98|7.57|0.73
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]|9.96||||9.96|4.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|9.96||||9.96|7.57|7.57|0.73
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]|9.96||||9.96|3.88|7.57|0.73
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]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|9.96||||9.96|6.87|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|CIGNA [1260]|CIGNA PPO [126025]|9.96||||9.96|3.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|9.96||||9.96|4.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|9.96||||9.96|6.87|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|9.96||||9.96|0.73|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|9.96||||9.96|6.87|7.57|0.73
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]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.96||||9.96|3.88|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.96||||9.96|0|7.57|0.73
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]|9.96||||9.96|3.88|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|9.96||||9.96|6.87|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.96||||9.96|3.88|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|Self-pay|Self-pay|9.96||||9.96|1.99|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|TML [1980]|TML [198000]|9.96||||9.96|6.87|7.57|0.73
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]|9.96||||9.96|3.88|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.96||||9.96|4.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UNICARE [2040]|UNICARE [204000]|9.96||||9.96|4.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.96||||9.96|4.98|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|WEB TPA [2115]|WEB TPA [211500]|9.96||||9.96|6.87|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.96||||9.96|0|7.57|0.73
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]|9.96||||9.96|0|7.57|0.73
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|WORKER'S COMP [2125]|TML WC [212537]|9.96||||9.96|4.98|7.57|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|12.61||||12.61|6.31|9.58|0.73
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]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.61||||12.61|4.91|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.61||||12.61|0.73|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.61||||12.61|4.91|9.58|0.73
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]|12.61||||12.61|0|9.58|0.73
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]|12.61||||12.61|9.08|9.58|0.73
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]|12.61||||12.61|6.31|9.58|0.73
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]|12.61||||12.61|6.31|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.61||||12.61|9.58|9.58|0.73
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]|12.61||||12.61|4.91|9.58|0.73
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]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.61||||12.61|8.7|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|12.61||||12.61|5.04|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.61||||12.61|6.31|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|12.61||||12.61|8.7|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.61||||12.61|0.73|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.61||||12.61|8.7|9.58|0.73
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]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.61||||12.61|4.91|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.61||||12.61|0|9.58|0.73
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]|12.61||||12.61|4.91|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|12.61||||12.61|8.7|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.61||||12.61|4.91|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|12.61||||12.61|2.52|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|12.61||||12.61|8.7|9.58|0.73
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]|12.61||||12.61|4.91|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.61||||12.61|6.31|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|12.61||||12.61|6.31|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.61||||12.61|6.31|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|12.61||||12.61|8.7|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.61||||12.61|0|9.58|0.73
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]|12.61||||12.61|0|9.58|0.73
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|12.61||||12.61|6.31|9.58|0.73
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|24.27||||24.27||18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|24.27||||24.27|12.14|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|24.27||||24.27|9.45|18.45|4.85
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]|24.27||||24.27|0|18.45|4.85
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]|24.27||||24.27|17.47|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.27||||24.27|12.14|18.45|4.85
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]|24.27||||24.27|12.14|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|24.27||||24.27|18.45|18.45|4.85
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]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|24.27||||24.27|16.75|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|24.27||||24.27|9.71|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|24.27||||24.27||18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|24.27||||24.27|16.75|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|24.27||||24.27|12.14|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|24.27||||24.27|16.75|18.45|4.85
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]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.27||||24.27|0|18.45|4.85
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]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|24.27||||24.27|16.75|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|Self-pay|Self-pay|24.27||||24.27|4.85|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|24.27||||24.27|16.75|18.45|4.85
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]|24.27||||24.27|9.45|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.27||||24.27||18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|24.27||||24.27||18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.27||||24.27||18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|24.27||||24.27|16.75|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.27||||24.27|0|18.45|4.85
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]|24.27||||24.27|0|18.45|4.85
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|24.27||||24.27||18.45|4.85
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.75||||1.75||1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.75||||1.75|0.88|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.75||||1.75|0.68|1.33|0.35
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]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.75||||1.75|1.26|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.75||||1.75|0.88|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.75||||1.75|0.88|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.75||||1.75|1.33|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.75||||1.75|1.21|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|1.75||||1.75|0.7|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.75||||1.75||1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.75||||1.75|1.21|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.75||||1.75|0.88|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.75||||1.75|1.21|1.33|0.35
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]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.75||||1.75|0|1.33|0.35
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]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.75||||1.75|1.21|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.75||||1.75|0.35|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|1.75||||1.75|1.21|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.75||||1.75|0.68|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.75||||1.75||1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|1.75||||1.75||1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.75||||1.75||1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|1.75||||1.75|1.21|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.75||||1.75|0|1.33|0.35
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]|1.75||||1.75|0|1.33|0.35
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|1.75||||1.75||1.33|0.35
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.88||||2.88||2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2.88||||2.88|1.44|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2.88||||2.88|1.12|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.88||||2.88|2.07|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.88||||2.88|1.44|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.88||||2.88|1.44|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2.88||||2.88|2.19|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2.88||||2.88|1.99|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|2.88||||2.88|1.15|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2.88||||2.88||2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.88||||2.88|1.99|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2.88||||2.88|1.44|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2.88||||2.88|1.99|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.88||||2.88|0|2.19|0.58
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]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.88||||2.88|1.99|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.88||||2.88|0.58|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|2.88||||2.88|1.99|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.88||||2.88|1.12|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.88||||2.88||2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|2.88||||2.88||2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.88||||2.88||2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|2.88||||2.88|1.99|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.88||||2.88|0|2.19|0.58
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]|2.88||||2.88|0|2.19|0.58
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|2.88||||2.88||2.19|0.58
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.93||||1.93||1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.93||||1.93|0.97|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.93||||1.93|0.75|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.93||||1.93|1.39|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.93||||1.93|0.97|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.93||||1.93|0.97|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.93||||1.93|1.47|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.93||||1.93|1.33|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.93||||1.93|0.77|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.93||||1.93||1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.93||||1.93|1.33|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.93||||1.93|0.97|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.93||||1.93|1.33|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.93||||1.93|0|1.47|0.39
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]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.93||||1.93|1.33|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.93||||1.93|0.39|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.93||||1.93|1.33|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.93||||1.93|0.75|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.93||||1.93||1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.93||||1.93||1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.93||||1.93||1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.93||||1.93|1.33|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.93||||1.93|0|1.47|0.39
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]|1.93||||1.93|0|1.47|0.39
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.93||||1.93||1.47|0.39
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AARP [1000]|AARP [100000]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AARP [1000]|AARP [100000]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA [1015]|AETNA [101529]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA [1015]|AETNA [101529]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMBETTER [2930]|AMBETTER [293000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMBETTER [2930]|AMBETTER [293000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17.43||||17.43|6.78|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|12.55|13.25|3.49
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]|17.43||||17.43|12.55|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.43||||17.43|8.72|13.25|3.49
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]|17.43||||17.43|8.72|13.25|3.49
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]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.43||||17.43|13.25|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17.43||||17.43|13.25|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA PPO [126025]|17.43||||17.43|6.97|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA PPO [126025]|17.43||||17.43|6.97|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17.43||||17.43|8.72|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17.43||||17.43|12.03|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|Self-pay|Self-pay|17.43||||17.43|3.49|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|Self-pay|Self-pay|17.43||||17.43|3.49|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|TML [1980]|TML [198000]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|TML [1980]|TML [198000]|17.43||||17.43|12.03|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
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]|17.43||||17.43|6.78|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNICARE [2040]|UNICARE [204000]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNICARE [2040]|UNICARE [204000]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WEB TPA [2115]|WEB TPA [211500]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WEB TPA [2115]|WEB TPA [211500]|17.43||||17.43|12.03|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
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]|17.43||||17.43|0|13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TML WC [212537]|17.43||||17.43||13.25|3.49
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TML WC [212537]|17.43||||17.43||13.25|3.49
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|3929.64||||3929.64||2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3929.64||||3929.64|68.16|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3929.64||||3929.64|2829.34|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3929.64||||3929.64|1964.82|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3929.64||||3929.64|1964.82|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3929.64||||3929.64|2986.53|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|3929.64||||3929.64|1571.86|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3929.64||||3929.64||2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3929.64||||3929.64|68.16|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|3929.64||||3929.64|785.93|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|TML [1980]|TML [198000]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3929.64||||3929.64|1529.42|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3929.64||||3929.64||2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UNICARE [2040]|UNICARE [204000]|3929.64||||3929.64||2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3929.64||||3929.64||2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|3929.64||||3929.64|2711.45|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3929.64||||3929.64|0|2986.53|68.16
9526|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|3929.64||||3929.64||2986.53|68.16
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]|26.92||||26.92||20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.92||||26.92|13.46|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|19.38|20.46|5.38
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]|26.92||||26.92|13.46|20.46|5.38
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]|26.92||||26.92|13.46|20.46|5.38
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 TRADITIONAL OF TEXAS [115503]|26.92||||26.92|20.46|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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 - GREAT WEST [126009]|26.92||||26.92|18.57|20.46|5.38
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 PPO [126025]|26.92||||26.92|10.77|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.92||||26.92||20.46|5.38
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]|26.92||||26.92|18.57|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.92||||26.92|13.46|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.92||||26.92|18.57|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92|18.57|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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|26.92||||26.92|5.38|20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|TML [1980]|TML [198000]|26.92||||26.92|18.57|20.46|5.38
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]|26.92||||26.92|10.48|20.46|5.38
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]|26.92||||26.92||20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|26.92||||26.92||20.46|5.38
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]|26.92||||26.92||20.46|5.38
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|26.92||||26.92|18.57|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|26.92||||26.92|0|20.46|5.38
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]|TML WC [212537]|26.92||||26.92||20.46|5.38
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|184.8||||184.8||140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMBETTER [2930]|AMBETTER [293000]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|184.8||||184.8|92.4|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|184.8||||184.8|71.92|140.45|36.96
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]|184.8||||184.8|0|140.45|36.96
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]|184.8||||184.8|133.06|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184.8||||184.8|92.4|140.45|36.96
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]|184.8||||184.8|92.4|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|184.8||||184.8|140.45|140.45|36.96
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]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|184.8||||184.8|127.51|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA PPO [126025]|184.8||||184.8|73.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|184.8||||184.8||140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|184.8||||184.8|127.51|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|184.8||||184.8|92.4|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|184.8||||184.8|127.51|140.45|36.96
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]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184.8||||184.8|0|140.45|36.96
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]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|184.8||||184.8|127.51|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|184.8||||184.8|36.96|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|TML [1980]|TML [198000]|184.8||||184.8|127.51|140.45|36.96
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]|184.8||||184.8|71.92|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184.8||||184.8||140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNICARE [2040]|UNICARE [204000]|184.8||||184.8||140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184.8||||184.8||140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WEB TPA [2115]|WEB TPA [211500]|184.8||||184.8|127.51|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184.8||||184.8|0|140.45|36.96
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]|184.8||||184.8|0|140.45|36.96
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TML WC [212537]|184.8||||184.8||140.45|36.96
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.9||||12.9||9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|12.9||||12.9|6.45|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.9||||12.9|9.29|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.9||||12.9|6.45|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.9||||12.9|6.45|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|12.9||||12.9|9.8|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|12.9||||12.9|5.16|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|12.9||||12.9||9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|12.9||||12.9|6.45|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|12.9||||12.9|2.58|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|TML [1980]|TML [198000]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.9||||12.9|5.02|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.9||||12.9||9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|12.9||||12.9||9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.9||||12.9||9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|12.9||||12.9|8.9|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.9||||12.9|0|9.8|2.58
9616|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|12.9||||12.9||9.8|2.58
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|103.62||||103.62||78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|103.62||||103.62|51.81|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103.62||||103.62|74.61|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103.62||||103.62|51.81|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103.62||||103.62|51.81|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|103.62||||103.62|78.75|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|103.62||||103.62|41.45|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|103.62||||103.62||78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|103.62||||103.62|51.81|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|103.62||||103.62|20.72|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103.62||||103.62|40.33|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103.62||||103.62||78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|103.62||||103.62||78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103.62||||103.62||78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|103.62||||103.62|71.5|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103.62||||103.62|0|78.75|20.72
9625|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|103.62||||103.62||78.75|20.72
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|156.42||||156.42||118.88|31.28
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]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156.42||||156.42|60.88|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|156.42||||156.42|78.21|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|156.42||||156.42|60.88|118.88|31.28
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]|156.42||||156.42|0|118.88|31.28
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]|156.42||||156.42|112.62|118.88|31.28
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]|156.42||||156.42|78.21|118.88|31.28
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]|156.42||||156.42|78.21|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|156.42||||156.42|118.88|118.88|31.28
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]|156.42||||156.42|60.88|118.88|31.28
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]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|156.42||||156.42|107.93|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|156.42||||156.42|62.57|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|156.42||||156.42||118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|156.42||||156.42|107.93|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|156.42||||156.42|78.21|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|156.42||||156.42|107.93|118.88|31.28
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]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156.42||||156.42|60.88|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156.42||||156.42|0|118.88|31.28
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]|156.42||||156.42|60.88|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|156.42||||156.42|107.93|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156.42||||156.42|60.88|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|156.42||||156.42|31.28|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|156.42||||156.42|107.93|118.88|31.28
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]|156.42||||156.42|60.88|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156.42||||156.42||118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|156.42||||156.42||118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156.42||||156.42||118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|156.42||||156.42|107.93|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156.42||||156.42|0|118.88|31.28
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]|156.42||||156.42|0|118.88|31.28
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|156.42||||156.42||118.88|31.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|191.4||||191.4||145.46|38.28
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]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMBETTER [2930]|AMBETTER [293000]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191.4||||191.4|74.49|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|191.4||||191.4|95.7|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|191.4||||191.4|74.49|145.46|38.28
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]|191.4||||191.4|0|145.46|38.28
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]|191.4||||191.4|137.81|145.46|38.28
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]|191.4||||191.4|95.7|145.46|38.28
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]|191.4||||191.4|95.7|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|191.4||||191.4|145.46|145.46|38.28
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]|191.4||||191.4|74.49|145.46|38.28
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]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|191.4||||191.4|132.07|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA PPO [126025]|191.4||||191.4|76.56|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|191.4||||191.4||145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|191.4||||191.4|132.07|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|191.4||||191.4|95.7|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|191.4||||191.4|132.07|145.46|38.28
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]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191.4||||191.4|74.49|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191.4||||191.4|0|145.46|38.28
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]|191.4||||191.4|74.49|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|191.4||||191.4|132.07|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191.4||||191.4|74.49|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|191.4||||191.4|38.28|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TML [1980]|TML [198000]|191.4||||191.4|132.07|145.46|38.28
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]|191.4||||191.4|74.49|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191.4||||191.4||145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNICARE [2040]|UNICARE [204000]|191.4||||191.4||145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191.4||||191.4||145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WEB TPA [2115]|WEB TPA [211500]|191.4||||191.4|132.07|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191.4||||191.4|0|145.46|38.28
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]|191.4||||191.4|0|145.46|38.28
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TML WC [212537]|191.4||||191.4||145.46|38.28
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AARP [1000]|AARP [100000]|26.13||||26.13||19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA [1015]|AETNA [101529]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMBETTER [2930]|AMBETTER [293000]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|26.13||||26.13|13.07|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|26.13||||26.13|10.17|19.86|5.23
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]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.13||||26.13|18.81|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.13||||26.13|13.07|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.13||||26.13|13.07|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|26.13||||26.13|19.86|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|26.13||||26.13|18.03|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|26.13||||26.13|10.45|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|26.13||||26.13||19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|26.13||||26.13|18.03|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|26.13||||26.13|13.07|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|26.13||||26.13|18.03|19.86|5.23
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]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.13||||26.13|0|19.86|5.23
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]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|26.13||||26.13|18.03|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|Self-pay|Self-pay|26.13||||26.13|5.23|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|TML [1980]|TML [198000]|26.13||||26.13|18.03|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.13||||26.13|10.17|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.13||||26.13||19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNICARE [2040]|UNICARE [204000]|26.13||||26.13||19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.13||||26.13||19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WEB TPA [2115]|WEB TPA [211500]|26.13||||26.13|18.03|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.13||||26.13|0|19.86|5.23
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]|26.13||||26.13|0|19.86|5.23
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|26.13||||26.13||19.86|5.23
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AARP [1000]|AARP [100000]|369.47||||369.47||280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AETNA [1015]|AETNA [101529]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AMBETTER [2930]|AMBETTER [293000]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|369.47||||369.47|18.01|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|369.47||||369.47|143.8|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|266.02|280.8|18.01
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]|369.47||||369.47|184.74|280.8|18.01
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]|369.47||||369.47|184.74|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|369.47||||369.47|280.8|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|369.47||||369.47|254.93|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|CIGNA [1260]|CIGNA PPO [126025]|369.47||||369.47|147.79|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|369.47||||369.47||280.8|18.01
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]|369.47||||369.47|254.93|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|369.47||||369.47|18.01|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|369.47||||369.47|254.93|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|369.47||||369.47|254.93|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|Self-pay|Self-pay|369.47||||369.47|73.89|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|TML [1980]|TML [198000]|369.47||||369.47|254.93|280.8|18.01
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]|369.47||||369.47|143.8|280.8|18.01
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]|369.47||||369.47||280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UNICARE [2040]|UNICARE [204000]|369.47||||369.47||280.8|18.01
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]|369.47||||369.47||280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|WEB TPA [2115]|WEB TPA [211500]|369.47||||369.47|254.93|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
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]|369.47||||369.47|0|280.8|18.01
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|WORKER'S COMP [2125]|TML WC [212537]|369.47||||369.47||280.8|18.01
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AARP [1000]|AARP [100000]|1406.86||||1406.86||1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AETNA [1015]|AETNA [101529]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMBETTER [2930]|AMBETTER [293000]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1406.86||||1406.86|41.93|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1406.86||||1406.86|547.55|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|1012.94|1069.21|41.93
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]|1406.86||||1406.86|703.43|1069.21|41.93
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]|1406.86||||1406.86|703.43|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1406.86||||1406.86|1069.21|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1406.86||||1406.86|970.73|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA [1260]|CIGNA PPO [126025]|1406.86||||1406.86|562.74|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1406.86||||1406.86||1069.21|41.93
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]|1406.86||||1406.86|970.73|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1406.86||||1406.86|41.93|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1406.86||||1406.86|970.73|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1406.86||||1406.86|970.73|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|Self-pay|Self-pay|1406.86||||1406.86|281.37|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|TML [1980]|TML [198000]|1406.86||||1406.86|970.73|1069.21|41.93
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]|1406.86||||1406.86|547.55|1069.21|41.93
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]|1406.86||||1406.86||1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNICARE [2040]|UNICARE [204000]|1406.86||||1406.86||1069.21|41.93
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]|1406.86||||1406.86||1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WEB TPA [2115]|WEB TPA [211500]|1406.86||||1406.86|970.73|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
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]|1406.86||||1406.86|0|1069.21|41.93
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WORKER'S COMP [2125]|TML WC [212537]|1406.86||||1406.86||1069.21|41.93
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|131.42||||131.42||99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|131.42||||131.42|65.71|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|131.42||||131.42|51.15|99.88|26.28
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]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131.42||||131.42|94.62|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131.42||||131.42|65.71|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131.42||||131.42|65.71|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|131.42||||131.42|99.88|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|131.42||||131.42|90.68|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|131.42||||131.42|52.57|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|131.42||||131.42||99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|131.42||||131.42|90.68|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|131.42||||131.42|65.71|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|131.42||||131.42|90.68|99.88|26.28
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]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131.42||||131.42|0|99.88|26.28
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]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|131.42||||131.42|90.68|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|131.42||||131.42|26.28|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|TML [1980]|TML [198000]|131.42||||131.42|90.68|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131.42||||131.42|51.15|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131.42||||131.42||99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|131.42||||131.42||99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131.42||||131.42||99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|131.42||||131.42|90.68|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131.42||||131.42|0|99.88|26.28
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]|131.42||||131.42|0|99.88|26.28
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|131.42||||131.42||99.88|26.28
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|205.46||||205.46||156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|205.46||||205.46|102.73|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205.46||||205.46|147.93|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205.46||||205.46|102.73|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205.46||||205.46|102.73|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|205.46||||205.46|156.15|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|205.46||||205.46|82.18|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|205.46||||205.46||156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|205.46||||205.46|102.73|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|205.46||||205.46|41.09|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|TML [1980]|TML [198000]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205.46||||205.46|79.97|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.46||||205.46||156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|205.46||||205.46||156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205.46||||205.46||156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|205.46||||205.46|141.77|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205.46||||205.46|0|156.15|41.09
96969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|205.46||||205.46||156.15|41.09
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|1078.71||||1078.71||819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1078.71||||1078.71|539.36|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1078.71||||1078.71|776.67|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1078.71||||1078.71|539.36|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1078.71||||1078.71|539.36|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1078.71||||1078.71|819.82|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA PPO [126025]|1078.71||||1078.71|431.48|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1078.71||||1078.71||819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1078.71||||1078.71|539.36|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|1078.71||||1078.71|215.74|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1078.71||||1078.71|419.83|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1078.71||||1078.71||819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|1078.71||||1078.71||819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1078.71||||1078.71||819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|1078.71||||1078.71|744.31|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1078.71||||1078.71|0|819.82|215.74
96972|ERX|0250 - PHARMACY-GENERAL|LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TML WC [212537]|1078.71||||1078.71||819.82|215.74
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|33.4||||33.4||25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33.4||||33.4|16.7|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.4||||33.4|24.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.4||||33.4|16.7|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.4||||33.4|16.7|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33.4||||33.4|25.38|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|33.4||||33.4|13.36|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33.4||||33.4||25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33.4||||33.4|16.7|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|Self-pay|Self-pay|33.4||||33.4|6.68|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|TML [1980]|TML [198000]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.4||||33.4|13|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.4||||33.4||25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|33.4||||33.4||25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.4||||33.4||25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|33.4||||33.4|23.05|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.4||||33.4|0|25.38|6.68
97133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|33.4||||33.4|16.7|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.4||||33.4|24.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.4||||33.4|16.7|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.4||||33.4|16.7|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|33.4||||33.4|25.38|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|33.4||||33.4|13.36|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|33.4||||33.4|16.7|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|Self-pay|Self-pay|33.4||||33.4|6.68|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|TML [1980]|TML [198000]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.4||||33.4|13|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.4||||33.4||25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|33.4||||33.4|23.05|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.4||||33.4|0|25.38|6.68
97134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEBUXOSTAT 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|33.4||||33.4||25.38|6.68
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|21.49||||21.49||16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMBETTER [2930]|AMBETTER [293000]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|21.49||||21.49|10.75|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|21.49||||21.49|8.36|16.33|4.3
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]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.49||||21.49|15.47|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.49||||21.49|10.75|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.49||||21.49|10.75|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|21.49||||21.49|16.33|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA - GREAT WEST [126009]|21.49||||21.49|14.83|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA PPO [126025]|21.49||||21.49|8.6|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|21.49||||21.49||16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.49||||21.49|14.83|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|21.49||||21.49|10.75|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|21.49||||21.49|14.83|16.33|4.3
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]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.49||||21.49|0|16.33|4.3
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]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.49||||21.49|14.83|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|21.49||||21.49|4.3|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|TML [1980]|TML [198000]|21.49||||21.49|14.83|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.49||||21.49|8.36|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.49||||21.49||16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNICARE [2040]|UNICARE [204000]|21.49||||21.49||16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.49||||21.49||16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WEB TPA [2115]|WEB TPA [211500]|21.49||||21.49|14.83|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.49||||21.49|0|16.33|4.3
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]|21.49||||21.49|0|16.33|4.3
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TML WC [212537]|21.49||||21.49||16.33|4.3
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|543.84||||543.84||413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AMBETTER [2930]|AMBETTER [293000]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|543.84||||543.84|10.27|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|543.84||||543.84|391.56|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|543.84||||543.84|271.92|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|543.84||||543.84|271.92|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|543.84||||543.84|413.32|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA PPO [126025]|543.84||||543.84|217.54|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|543.84||||543.84||413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|543.84||||543.84|10.27|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|543.84||||543.84|108.77|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|TML [1980]|TML [198000]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|543.84||||543.84|211.66|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|543.84||||543.84||413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|UNICARE [2040]|UNICARE [204000]|543.84||||543.84||413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|543.84||||543.84||413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|WEB TPA [2115]|WEB TPA [211500]|543.84||||543.84|375.25|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|543.84||||543.84|0|413.32|10.27
9722|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TML WC [212537]|543.84||||543.84||413.32|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|170.94||||170.94||129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AMBETTER [2930]|AMBETTER [293000]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|170.94||||170.94|10.27|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.94||||170.94|123.08|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.94||||170.94|85.47|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.94||||170.94|85.47|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|170.94||||170.94|129.91|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA PPO [126025]|170.94||||170.94|68.38|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|170.94||||170.94||129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|170.94||||170.94|10.27|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|170.94||||170.94|34.19|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|TML [1980]|TML [198000]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.94||||170.94|66.53|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.94||||170.94||129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|UNICARE [2040]|UNICARE [204000]|170.94||||170.94||129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.94||||170.94||129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|WEB TPA [2115]|WEB TPA [211500]|170.94||||170.94|117.95|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.94||||170.94|0|129.91|10.27
9723|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEFEROXAMINE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TML WC [212537]|170.94||||170.94||129.91|10.27
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|83.23||||83.23||63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|83.23||||83.23|41.62|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|83.23||||83.23|32.39|63.25|16.65
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]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.23||||83.23|59.93|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.23||||83.23|41.62|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.23||||83.23|41.62|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|83.23||||83.23|63.25|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|83.23||||83.23|57.43|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|83.23||||83.23|33.29|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|83.23||||83.23||63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|83.23||||83.23|57.43|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|83.23||||83.23|41.62|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|83.23||||83.23|57.43|63.25|16.65
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]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.23||||83.23|0|63.25|16.65
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]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|83.23||||83.23|57.43|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|83.23||||83.23|16.65|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|TML [1980]|TML [198000]|83.23||||83.23|57.43|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.23||||83.23|32.39|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.23||||83.23||63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|83.23||||83.23||63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.23||||83.23||63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|83.23||||83.23|57.43|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.23||||83.23|0|63.25|16.65
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]|83.23||||83.23|0|63.25|16.65
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|83.23||||83.23||63.25|16.65
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AARP [1000]|AARP [100000]|476.52||||476.52||362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AETNA [1015]|AETNA [101529]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AMBETTER [2930]|AMBETTER [293000]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|476.52||||476.52|238.26|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|476.52||||476.52|343.09|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|476.52||||476.52|238.26|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|476.52||||476.52|238.26|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|476.52||||476.52|362.16|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|CIGNA [1260]|CIGNA PPO [126025]|476.52||||476.52|190.61|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|476.52||||476.52||362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|476.52||||476.52|238.26|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|Self-pay|Self-pay|476.52||||476.52|95.3|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|TML [1980]|TML [198000]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|476.52||||476.52|185.46|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|476.52||||476.52||362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|UNICARE [2040]|UNICARE [204000]|476.52||||476.52||362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|476.52||||476.52||362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|WEB TPA [2115]|WEB TPA [211500]|476.52||||476.52|328.8|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|476.52||||476.52|0|362.16|95.3
97296|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION|1,900 mL|WORKER'S COMP [2125]|TML WC [212537]|476.52||||476.52||362.16|95.3
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|330||||330||250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMBETTER [2930]|AMBETTER [293000]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|330||||330|165|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|330||||330|128.44|250.8|66
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]|330||||330|0|250.8|66
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]|330||||330|237.6|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|330||||330|165|250.8|66
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]|330||||330|165|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|330||||330|250.8|250.8|66
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]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|330||||330|227.7|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA PPO [126025]|330||||330|132|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|330||||330||250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|330||||330|227.7|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|330||||330|165|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|330||||330|227.7|250.8|66
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]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|330||||330|0|250.8|66
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]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|330||||330|227.7|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|Self-pay|Self-pay|330||||330|66|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|TML [1980]|TML [198000]|330||||330|227.7|250.8|66
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]|330||||330|128.44|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|330||||330||250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNICARE [2040]|UNICARE [204000]|330||||330||250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|330||||330||250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WEB TPA [2115]|WEB TPA [211500]|330||||330|227.7|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|330||||330|0|250.8|66
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]|330||||330|0|250.8|66
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TML WC [212537]|330||||330||250.8|66
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AARP [1000]|AARP [100000]|128.55||||128.55|64.28|97.7|3.39
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]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AETNA [1015]|AETNA [101529]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMBETTER [2930]|AMBETTER [293000]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.55||||128.55|50.03|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|128.55||||128.55|3.39|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|128.55||||128.55|50.03|97.7|3.39
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]|128.55||||128.55|0|97.7|3.39
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]|128.55||||128.55|92.56|97.7|3.39
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]|128.55||||128.55|64.28|97.7|3.39
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]|128.55||||128.55|64.28|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|128.55||||128.55|97.7|97.7|3.39
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]|128.55||||128.55|50.03|97.7|3.39
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]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|128.55||||128.55|88.7|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA [1260]|CIGNA PPO [126025]|128.55||||128.55|51.42|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|128.55||||128.55|64.28|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|GROUP PENSION ADMIN [1450]|GPA [145000]|128.55||||128.55|88.7|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|128.55||||128.55|3.39|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|128.55||||128.55|88.7|97.7|3.39
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]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.55||||128.55|50.03|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.55||||128.55|0|97.7|3.39
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]|128.55||||128.55|50.03|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|PHCS [1780]|PHCS MULTIPLAN [178000]|128.55||||128.55|88.7|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.55||||128.55|50.03|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|Self-pay|Self-pay|128.55||||128.55|25.71|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|TML [1980]|TML [198000]|128.55||||128.55|88.7|97.7|3.39
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]|128.55||||128.55|50.03|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.55||||128.55|64.28|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNICARE [2040]|UNICARE [204000]|128.55||||128.55|64.28|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.55||||128.55|64.28|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WEB TPA [2115]|WEB TPA [211500]|128.55||||128.55|88.7|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.55||||128.55|0|97.7|3.39
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]|128.55||||128.55|0|97.7|3.39
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WORKER'S COMP [2125]|TML WC [212537]|128.55||||128.55|64.28|97.7|3.39
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AARP [1000]|AARP [100000]|2116.23||||2116.23||1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AETNA [1015]|AETNA [101529]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AMBETTER [2930]|AMBETTER [293000]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|2116.23||||2116.23|1058.12|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2116.23||||2116.23|1523.69|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2116.23||||2116.23|1058.12|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2116.23||||2116.23|1058.12|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|2116.23||||2116.23|1608.33|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA [1260]|CIGNA PPO [126025]|2116.23||||2116.23|846.49|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|2116.23||||2116.23||1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|2116.23||||2116.23|1058.12|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|Self-pay|Self-pay|2116.23||||2116.23|423.25|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|TML [1980]|TML [198000]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2116.23||||2116.23|823.64|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2116.23||||2116.23||1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UNICARE [2040]|UNICARE [204000]|2116.23||||2116.23||1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2116.23||||2116.23||1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WEB TPA [2115]|WEB TPA [211500]|2116.23||||2116.23|1460.2|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2116.23||||2116.23|0|1608.33|423.25
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WORKER'S COMP [2125]|TML WC [212537]|2116.23||||2116.23||1608.33|423.25
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|785.67||||785.67||597.11|13.74
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]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785.67||||785.67|305.78|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|785.67||||785.67|13.74|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|785.67||||785.67|305.78|597.11|13.74
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]|785.67||||785.67|0|597.11|13.74
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]|785.67||||785.67|565.68|597.11|13.74
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]|785.67||||785.67|392.84|597.11|13.74
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]|785.67||||785.67|392.84|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|785.67||||785.67|597.11|597.11|13.74
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]|785.67||||785.67|305.78|597.11|13.74
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]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|785.67||||785.67|542.11|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|785.67||||785.67|314.27|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|785.67||||785.67||597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|785.67||||785.67|542.11|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|785.67||||785.67|13.74|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|785.67||||785.67|542.11|597.11|13.74
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]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785.67||||785.67|305.78|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785.67||||785.67|0|597.11|13.74
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]|785.67||||785.67|305.78|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|785.67||||785.67|542.11|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785.67||||785.67|305.78|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|785.67||||785.67|157.13|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|785.67||||785.67|542.11|597.11|13.74
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]|785.67||||785.67|305.78|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785.67||||785.67||597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|785.67||||785.67||597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785.67||||785.67||597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|785.67||||785.67|542.11|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785.67||||785.67|0|597.11|13.74
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]|785.67||||785.67|0|597.11|13.74
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|785.67||||785.67||597.11|13.74
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|27.46||||27.46||20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AMBETTER [2930]|AMBETTER [293000]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|27.46||||27.46|13.73|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.46||||27.46|19.77|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.46||||27.46|13.73|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.46||||27.46|13.73|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|27.46||||27.46|20.87|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA PPO [126025]|27.46||||27.46|10.98|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|27.46||||27.46||20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|27.46||||27.46|13.73|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|27.46||||27.46|5.49|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|TML [1980]|TML [198000]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.46||||27.46|10.69|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.46||||27.46||20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|UNICARE [2040]|UNICARE [204000]|27.46||||27.46||20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.46||||27.46||20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|WEB TPA [2115]|WEB TPA [211500]|27.46||||27.46|18.95|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.46||||27.46|0|20.87|5.49
9774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TML WC [212537]|27.46||||27.46||20.87|5.49
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|3307.4||||3307.4|1653.7|2513.62|1.11
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]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMBETTER [2930]|AMBETTER [293000]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3307.4||||3307.4|1287.24|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3307.4||||3307.4|1.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3307.4||||3307.4|1287.24|2513.62|1.11
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]|3307.4||||3307.4|0|2513.62|1.11
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]|3307.4||||3307.4|2381.33|2513.62|1.11
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]|3307.4||||3307.4|1653.7|2513.62|1.11
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]|3307.4||||3307.4|1653.7|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3307.4||||3307.4|2513.62|2513.62|1.11
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]|3307.4||||3307.4|1287.24|2513.62|1.11
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]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3307.4||||3307.4|2282.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA PPO [126025]|3307.4||||3307.4|1322.96|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3307.4||||3307.4|1653.7|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3307.4||||3307.4|2282.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3307.4||||3307.4|1.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3307.4||||3307.4|2282.11|2513.62|1.11
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]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3307.4||||3307.4|1287.24|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3307.4||||3307.4|0|2513.62|1.11
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]|3307.4||||3307.4|1287.24|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3307.4||||3307.4|2282.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3307.4||||3307.4|1287.24|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|3307.4||||3307.4|661.48|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|TML [1980]|TML [198000]|3307.4||||3307.4|2282.11|2513.62|1.11
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]|3307.4||||3307.4|1287.24|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3307.4||||3307.4|1653.7|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNICARE [2040]|UNICARE [204000]|3307.4||||3307.4|1653.7|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3307.4||||3307.4|1653.7|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WEB TPA [2115]|WEB TPA [211500]|3307.4||||3307.4|2282.11|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3307.4||||3307.4|0|2513.62|1.11
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]|3307.4||||3307.4|0|2513.62|1.11
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TML WC [212537]|3307.4||||3307.4|1653.7|2513.62|1.11
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|28.51|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.6||||39.6|19.8|30.1|7.92
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]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|7.92
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]|39.6||||39.6|15.41|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.6||||39.6|19.8|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.6||||39.6|0|30.1|7.92
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]|39.6||||39.6|0|30.1|7.92
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|30.1|7.92
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6187.1||||6187.1||4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6187.1||||6187.1|3093.55|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6187.1||||6187.1|4454.71|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6187.1||||6187.1|3093.55|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6187.1||||6187.1|3093.55|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6187.1||||6187.1|4702.2|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|6187.1||||6187.1|2474.84|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6187.1||||6187.1||4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6187.1||||6187.1|3093.55|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|Self-pay|Self-pay|6187.1||||6187.1|1237.42|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|TML [1980]|TML [198000]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6187.1||||6187.1|2408.02|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6187.1||||6187.1||4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|6187.1||||6187.1||4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6187.1||||6187.1||4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|6187.1||||6187.1|4269.1|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6187.1||||6187.1|0|4702.2|1237.42
97894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|6187.1||||6187.1||4702.2|1237.42
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|0.21|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.4||||92.4|66.53|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|0.21|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|92.4||||92.4|18.48|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.4||||92.4|35.96|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.4||||92.4|46.2|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.4||||92.4|0|70.22|0.21
9791|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|92.4||||92.4|46.2|70.22|0.21
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]|66||||66||50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|0|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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]|66||||66|0|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|33|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|47.52|50.16|13.2
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]|66||||66|33|50.16|13.2
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]|66||||66|33|50.16|13.2
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 TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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]|66||||66|0|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66||50.16|13.2
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]|66||||66|45.54|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|33|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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]|66||||66|45.54|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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|66||||66|13.2|50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|50.16|13.2
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]|66||||66|25.69|50.16|13.2
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]|66||||66||50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66||50.16|13.2
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]|66||||66||50.16|13.2
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|66||||66|0|50.16|13.2
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]|TML WC [212537]|66||||66||50.16|13.2
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]|92.4||||92.4||70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|92.4||||92.4|46.2|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|66.53|70.22|18.48
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]|92.4||||92.4|46.2|70.22|18.48
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]|92.4||||92.4|46.2|70.22|18.48
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 TRADITIONAL OF TEXAS [115503]|92.4||||92.4|70.22|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|92.4||||92.4|63.76|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|92.4||||92.4|36.96|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|92.4||||92.4||70.22|18.48
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]|92.4||||92.4|63.76|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|92.4||||92.4|46.2|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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|92.4||||92.4|18.48|70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TML [1980]|TML [198000]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|35.96|70.22|18.48
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]|92.4||||92.4||70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNICARE [2040]|UNICARE [204000]|92.4||||92.4||70.22|18.48
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]|92.4||||92.4||70.22|18.48
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|92.4||||92.4|63.76|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|92.4||||92.4|0|70.22|18.48
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]|TML WC [212537]|92.4||||92.4||70.22|18.48
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|66||||66|33|50.16|1.57
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]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|25.69|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|66||||66|1.57|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|66||||66|25.69|50.16|1.57
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]|66||||66|0|50.16|1.57
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]|66||||66|47.52|50.16|1.57
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]|66||||66|33|50.16|1.57
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]|66||||66|33|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|66||||66|50.16|50.16|1.57
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]|66||||66|25.69|50.16|1.57
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]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|66||||66|45.54|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|66||||66|26.4|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|66||||66|33|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|66||||66|1.57|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|66||||66|45.54|50.16|1.57
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]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|0|50.16|1.57
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]|66||||66|25.69|50.16|1.57
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]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|0|50.16|1.57
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]|66||||66|25.69|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|50.16|1.57
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]|66||||66|25.69|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|66||||66|13.2|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|66||||66|45.54|50.16|1.57
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]|66||||66|25.69|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66|33|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|66||||66|33|50.16|1.57
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]|66||||66|33|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|66||||66|45.54|50.16|1.57
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]|66||||66|0|50.16|1.57
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]|66||||66|0|50.16|1.57
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|66||||66|33|50.16|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|1.57|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|28.51|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|1.57|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|19.8|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMBETTER [2930]|AMBETTER [293000]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.6||||39.6|15.41|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|39.6||||39.6|1.57|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|28.51|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|39.6||||39.6|30.1|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|39.6||||39.6|27.32|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA PPO [126025]|39.6||||39.6|15.84|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|39.6||||39.6|19.8|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.6||||39.6|27.32|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|39.6||||39.6|1.57|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|39.6||||39.6|7.92|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TML [1980]|TML [198000]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|15.41|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.6||||39.6|19.8|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNICARE [2040]|UNICARE [204000]|39.6||||39.6|19.8|30.1|1.57
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]|39.6||||39.6|19.8|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WEB TPA [2115]|WEB TPA [211500]|39.6||||39.6|27.32|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
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]|39.6||||39.6|0|30.1|1.57
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TML WC [212537]|39.6||||39.6|19.8|30.1|1.57
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|152.1||||152.1||115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|152.1||||152.1|76.05|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|152.1||||152.1|59.2|115.6|30.42
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]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152.1||||152.1|109.51|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152.1||||152.1|76.05|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152.1||||152.1|76.05|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|152.1||||152.1|115.6|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|152.1||||152.1|104.95|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|152.1||||152.1|60.84|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|152.1||||152.1||115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|152.1||||152.1|104.95|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|152.1||||152.1|76.05|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|152.1||||152.1|104.95|115.6|30.42
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]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152.1||||152.1|0|115.6|30.42
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]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|152.1||||152.1|104.95|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|Self-pay|Self-pay|152.1||||152.1|30.42|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|TML [1980]|TML [198000]|152.1||||152.1|104.95|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152.1||||152.1|59.2|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152.1||||152.1||115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|152.1||||152.1||115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152.1||||152.1||115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|152.1||||152.1|104.95|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152.1||||152.1|0|115.6|30.42
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]|152.1||||152.1|0|115.6|30.42
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|152.1||||152.1||115.6|30.42
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.89||||10.89||8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.89||||10.89|5.45|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.89||||10.89|4.24|8.28|2.18
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]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.89||||10.89|7.84|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.89||||10.89|5.45|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.89||||10.89|5.45|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.89||||10.89|8.28|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.89||||10.89|7.51|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.89||||10.89|4.36|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.89||||10.89||8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.89||||10.89|7.51|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.89||||10.89|5.45|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.89||||10.89|7.51|8.28|2.18
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]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.89||||10.89|0|8.28|2.18
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]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.89||||10.89|7.51|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|Self-pay|Self-pay|10.89||||10.89|2.18|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.89||||10.89|7.51|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.89||||10.89|4.24|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.89||||10.89||8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.89||||10.89||8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.89||||10.89||8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.89||||10.89|7.51|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.89||||10.89|0|8.28|2.18
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]|10.89||||10.89|0|8.28|2.18
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.89||||10.89||8.28|2.18
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|201.96||||201.96||153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|201.96||||201.96|100.98|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|201.96||||201.96|145.41|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|201.96||||201.96|100.98|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|201.96||||201.96|100.98|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|201.96||||201.96|153.49|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|201.96||||201.96|80.78|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|201.96||||201.96||153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|201.96||||201.96|100.98|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|Self-pay|Self-pay|201.96||||201.96|40.39|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|TML [1980]|TML [198000]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|201.96||||201.96|78.6|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|201.96||||201.96||153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|201.96||||201.96||153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|201.96||||201.96||153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|201.96||||201.96|139.35|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|201.96||||201.96|0|153.49|40.39
98373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|201.96||||201.96||153.49|40.39
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||13307.22|3501.9
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|0|13307.22|3501.9
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|0|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AMBETTER [2930]|AMBETTER [293000]|17509.5||||17509.5|0|13307.22|3501.9
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|6814.7|13307.22|3501.9
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|0|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|17509.5||||17509.5|8754.75|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|17509.5||||17509.5|6814.7|13307.22|3501.9
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|0|13307.22|3501.9
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|12606.84|13307.22|3501.9
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|13307.22|3501.9
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|8754.75|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|17509.5||||17509.5|13307.22|13307.22|3501.9
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|6814.7|13307.22|3501.9
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|0|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|17509.5||||17509.5|12081.56|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA PPO [126025]|17509.5||||17509.5|7003.8|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|17509.5||||17509.5||13307.22|3501.9
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|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|17509.5||||17509.5|8754.75|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|17509.5||||17509.5|12081.56|13307.22|3501.9
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|0|13307.22|3501.9
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|0|13307.22|3501.9
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|6814.7|13307.22|3501.9
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|0|13307.22|3501.9
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|0|13307.22|3501.9
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|6814.7|13307.22|3501.9
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|13307.22|3501.9
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|6814.7|13307.22|3501.9
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|3501.9|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|TML [1980]|TML [198000]|17509.5||||17509.5|12081.56|13307.22|3501.9
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|6814.7|13307.22|3501.9
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||13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UNICARE [2040]|UNICARE [204000]|17509.5||||17509.5||13307.22|3501.9
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||13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|WEB TPA [2115]|WEB TPA [211500]|17509.5||||17509.5|12081.56|13307.22|3501.9
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|0|13307.22|3501.9
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|0|13307.22|3501.9
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|WORKER'S COMP [2125]|TML WC [212537]|17509.5||||17509.5||13307.22|3501.9
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AARP [1000]|AARP [100000]|6600||||6600||5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AETNA [1015]|AETNA [101529]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AMBETTER [2930]|AMBETTER [293000]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|6600||||6600|3300|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6600||||6600|4752|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6600||||6600|3300|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6600||||6600|3300|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|6600||||6600|5016|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA PPO [126025]|6600||||6600|2640|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|6600||||6600||5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|6600||||6600|3300|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|Self-pay|Self-pay|6600||||6600|1320|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|TML [1980]|TML [198000]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6600||||6600|2568.72|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6600||||6600||5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|UNICARE [2040]|UNICARE [204000]|6600||||6600||5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6600||||6600||5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|WEB TPA [2115]|WEB TPA [211500]|6600||||6600|4554|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6600||||6600|0|5016|1320
98453|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M EXAMETAZIME (CERETEC) PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TML WC [212537]|6600||||6600||5016|1320
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AARP [1000]|AARP [100000]|102||||102||77.52|20.4
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|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AETNA [1015]|AETNA [101529]|102||||102|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AMBETTER [2930]|AMBETTER [293000]|102||||102|0|77.52|20.4
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|39.7|77.52|20.4
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|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|102||||102|51|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|102||||102|39.7|77.52|20.4
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|0|77.52|20.4
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|73.44|77.52|20.4
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|77.52|20.4
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|51|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|102||||102|77.52|77.52|20.4
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|39.7|77.52|20.4
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|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|CIGNA [1260]|CIGNA - GREAT WEST [126009]|102||||102|70.38|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|CIGNA [1260]|CIGNA PPO [126025]|102||||102|40.8|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|102||||102||77.52|20.4
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|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|102||||102|51|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|102||||102|70.38|77.52|20.4
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|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|77.52|20.4
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|39.7|77.52|20.4
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|0|77.52|20.4
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|77.52|20.4
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|39.7|77.52|20.4
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|77.52|20.4
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|39.7|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|Self-pay|Self-pay|102||||102|20.4|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|TML [1980]|TML [198000]|102||||102|70.38|77.52|20.4
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|39.7|77.52|20.4
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||77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UNICARE [2040]|UNICARE [204000]|102||||102||77.52|20.4
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||77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|WEB TPA [2115]|WEB TPA [211500]|102||||102|70.38|77.52|20.4
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|0|77.52|20.4
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|0|77.52|20.4
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|WORKER'S COMP [2125]|TML WC [212537]|102||||102||77.52|20.4
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|1973.4||||1973.4||1499.78|74.41
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]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AMBETTER [2930]|AMBETTER [293000]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1973.4||||1973.4|768.05|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1973.4||||1973.4|74.41|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1973.4||||1973.4|768.05|1499.78|74.41
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]|1973.4||||1973.4|0|1499.78|74.41
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]|1973.4||||1973.4|1420.85|1499.78|74.41
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]|1973.4||||1973.4|986.7|1499.78|74.41
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]|1973.4||||1973.4|986.7|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1973.4||||1973.4|1499.78|1499.78|74.41
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]|1973.4||||1973.4|768.05|1499.78|74.41
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]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1973.4||||1973.4|1361.65|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA PPO [126025]|1973.4||||1973.4|789.36|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1973.4||||1973.4||1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1973.4||||1973.4|1361.65|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1973.4||||1973.4|74.41|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1973.4||||1973.4|1361.65|1499.78|74.41
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]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1973.4||||1973.4|768.05|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1973.4||||1973.4|0|1499.78|74.41
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]|1973.4||||1973.4|768.05|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1973.4||||1973.4|1361.65|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1973.4||||1973.4|768.05|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|1973.4||||1973.4|394.68|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|TML [1980]|TML [198000]|1973.4||||1973.4|1361.65|1499.78|74.41
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]|1973.4||||1973.4|768.05|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1973.4||||1973.4||1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UNICARE [2040]|UNICARE [204000]|1973.4||||1973.4||1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1973.4||||1973.4||1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|WEB TPA [2115]|WEB TPA [211500]|1973.4||||1973.4|1361.65|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1973.4||||1973.4|0|1499.78|74.41
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]|1973.4||||1973.4|0|1499.78|74.41
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TML WC [212537]|1973.4||||1973.4||1499.78|74.41
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]|73.66||||73.66|36.83|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMBETTER [2930]|AMBETTER [293000]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|73.66||||73.66|9.35|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|53.04|55.98|9.35
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]|73.66||||73.66|36.83|55.98|9.35
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]|73.66||||73.66|36.83|55.98|9.35
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 TRADITIONAL OF TEXAS [115503]|73.66||||73.66|55.98|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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 - GREAT WEST [126009]|73.66||||73.66|50.83|55.98|9.35
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 PPO [126025]|73.66||||73.66|29.46|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|73.66||||73.66|36.83|55.98|9.35
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]|73.66||||73.66|50.83|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|73.66||||73.66|9.35|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|73.66||||73.66|50.83|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|50.83|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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|73.66||||73.66|14.73|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|TML [1980]|TML [198000]|73.66||||73.66|50.83|55.98|9.35
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]|73.66||||73.66|28.67|55.98|9.35
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]|73.66||||73.66|36.83|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNICARE [2040]|UNICARE [204000]|73.66||||73.66|36.83|55.98|9.35
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]|73.66||||73.66|36.83|55.98|9.35
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|WEB TPA [2115]|WEB TPA [211500]|73.66||||73.66|50.83|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|73.66||||73.66|0|55.98|9.35
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]|TML WC [212537]|73.66||||73.66|36.83|55.98|9.35
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.09||||3.09||2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|3.09||||3.09|1.55|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.09||||3.09|2.22|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.09||||3.09|1.55|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.09||||3.09|1.55|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|3.09||||3.09|2.35|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|3.09||||3.09|1.24|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|3.09||||3.09||2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|3.09||||3.09|1.55|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|Self-pay|Self-pay|3.09||||3.09|0.62|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.09||||3.09|1.2|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.09||||3.09||2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|3.09||||3.09||2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.09||||3.09||2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|3.09||||3.09|2.13|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.09||||3.09|0|2.35|0.62
9894|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|3.09||||3.09||2.35|0.62
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|41.35||||41.35||31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.35||||41.35|20.68|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.35||||41.35|16.09|31.43|8.27
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]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.35||||41.35|29.77|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.35||||41.35|20.68|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.35||||41.35|20.68|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.35||||41.35|31.43|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.35||||41.35|28.53|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|41.35||||41.35|16.54|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.35||||41.35||31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.35||||41.35|28.53|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.35||||41.35|20.68|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.35||||41.35|28.53|31.43|8.27
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]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.35||||41.35|0|31.43|8.27
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]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.35||||41.35|28.53|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|Self-pay|Self-pay|41.35||||41.35|8.27|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|TML [1980]|TML [198000]|41.35||||41.35|28.53|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.35||||41.35|16.09|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.35||||41.35||31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|41.35||||41.35||31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.35||||41.35||31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|41.35||||41.35|28.53|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.35||||41.35|0|31.43|8.27
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]|41.35||||41.35|0|31.43|8.27
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|41.35||||41.35||31.43|8.27
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AARP [1000]|AARP [100000]|41.46||||41.46||31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AETNA [1015]|AETNA [101529]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AMBETTER [2930]|AMBETTER [293000]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|41.46||||41.46|20.73|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.46||||41.46|29.85|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.46||||41.46|20.73|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.46||||41.46|20.73|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|41.46||||41.46|31.51|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|CIGNA [1260]|CIGNA - GREAT WEST [126009]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|CIGNA [1260]|CIGNA PPO [126025]|41.46||||41.46|16.58|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|41.46||||41.46||31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|41.46||||41.46|20.73|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|Self-pay|Self-pay|41.46||||41.46|8.29|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|TML [1980]|TML [198000]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.46||||41.46|16.14|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.46||||41.46||31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|UNICARE [2040]|UNICARE [204000]|41.46||||41.46||31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.46||||41.46||31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|WEB TPA [2115]|WEB TPA [211500]|41.46||||41.46|28.61|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.46||||41.46|0|31.51|8.29
99405|ERX|0250 - PHARMACY-GENERAL|OPIUM TINCTURE 10 MG/ML (MORPHINE) ORAL|0.6 mL|WORKER'S COMP [2125]|TML WC [212537]|41.46||||41.46||31.51|8.29
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.15||||1.15||0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|1.15||||1.15|0.58|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|1.15||||1.15|0.45|0.87|0.23
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]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.83|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.58|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|1.15||||1.15|0.87|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|1.15||||1.15|0.79|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|1.15||||1.15|0.46|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|1.15||||1.15||0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|1.15||||1.15|0.58|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|1.15||||1.15|0.79|0.87|0.23
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]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0|0.87|0.23
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]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.15||||1.15|0.23|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|TML [1980]|TML [198000]|1.15||||1.15|0.79|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.45|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|1.15||||1.15||0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|1.15||||1.15|0.79|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15|0|0.87|0.23
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]|1.15||||1.15|0|0.87|0.23
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|1.15||||1.15||0.87|0.23
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|235.6||||235.6||179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMBETTER [2930]|AMBETTER [293000]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|235.6||||235.6|117.8|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235.6||||235.6|169.63|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235.6||||235.6|117.8|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235.6||||235.6|117.8|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|235.6||||235.6|179.06|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA PPO [126025]|235.6||||235.6|94.24|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|235.6||||235.6||179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|235.6||||235.6|117.8|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|235.6||||235.6|47.12|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|TML [1980]|TML [198000]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235.6||||235.6|91.7|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235.6||||235.6||179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UNICARE [2040]|UNICARE [204000]|235.6||||235.6||179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235.6||||235.6||179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WEB TPA [2115]|WEB TPA [211500]|235.6||||235.6|162.56|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235.6||||235.6|0|179.06|47.12
99694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TML WC [212537]|235.6||||235.6||179.06|47.12
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AARP [1000]|AARP [100000]|4319.31||||4319.31||3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AETNA [1015]|AETNA [101529]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AMBETTER [2930]|AMBETTER [293000]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4319.31||||4319.31|1681.08|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|4319.31||||4319.31|423.16|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|4319.31||||4319.31|1681.08|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
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]|4319.31||||4319.31|3109.9|3282.68|423.16
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]|4319.31||||4319.31|2159.66|3282.68|423.16
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]|4319.31||||4319.31|2159.66|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|4319.31||||4319.31|3282.68|3282.68|423.16
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]|4319.31||||4319.31|1681.08|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|CIGNA [1260]|CIGNA - GREAT WEST [126009]|4319.31||||4319.31|2980.32|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|CIGNA [1260]|CIGNA PPO [126025]|4319.31||||4319.31|1727.72|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|4319.31||||4319.31||3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4319.31||||4319.31|2980.32|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|4319.31||||4319.31|423.16|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|4319.31||||4319.31|2980.32|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4319.31||||4319.31|0|3282.68|423.16
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]|4319.31||||4319.31|1681.08|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4319.31||||4319.31|0|3282.68|423.16
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]|4319.31||||4319.31|1681.08|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4319.31||||4319.31|2980.32|3282.68|423.16
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]|4319.31||||4319.31|1681.08|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|Self-pay|Self-pay|4319.31||||4319.31|863.86|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|TML [1980]|TML [198000]|4319.31||||4319.31|2980.32|3282.68|423.16
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]|4319.31||||4319.31|1681.08|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4319.31||||4319.31||3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UNICARE [2040]|UNICARE [204000]|4319.31||||4319.31||3282.68|423.16
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]|4319.31||||4319.31||3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|WEB TPA [2115]|WEB TPA [211500]|4319.31||||4319.31|2980.32|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
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]|4319.31||||4319.31|0|3282.68|423.16
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|WORKER'S COMP [2125]|TML WC [212537]|4319.31||||4319.31||3282.68|423.16
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|81.83||||81.83||62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.83||||81.83|31.85|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|81.83||||81.83|40.92|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|81.83||||81.83|31.85|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|58.92|62.19|16.37
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]|81.83||||81.83|40.92|62.19|16.37
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]|81.83||||81.83|40.92|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|81.83||||81.83|62.19|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|81.83||||81.83|56.46|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|81.83||||81.83|32.73|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|81.83||||81.83||62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|81.83||||81.83|56.46|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|81.83||||81.83|40.92|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|81.83||||81.83|56.46|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.83||||81.83|31.85|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|81.83||||81.83|56.46|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.83||||81.83|31.85|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|Self-pay|Self-pay|81.83||||81.83|16.37|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|TML [1980]|TML [198000]|81.83||||81.83|56.46|62.19|16.37
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]|81.83||||81.83|31.85|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.83||||81.83||62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|81.83||||81.83||62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.83||||81.83||62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|81.83||||81.83|56.46|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.83||||81.83|0|62.19|16.37
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]|81.83||||81.83|0|62.19|16.37
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|81.83||||81.83||62.19|16.37
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AARP [1000]|AARP [100000]|5332.94||||5332.94||4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AETNA [1015]|AETNA [101529]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMBETTER [2930]|AMBETTER [293000]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|5332.94||||5332.94|2666.47|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|5332.94||||5332.94|2075.58|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|3839.72|4053.03|1066.59
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]|5332.94||||5332.94|2666.47|4053.03|1066.59
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]|5332.94||||5332.94|2666.47|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|5332.94||||5332.94|4053.03|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA [1260]|CIGNA - GREAT WEST [126009]|5332.94||||5332.94|3679.73|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA [1260]|CIGNA PPO [126025]|5332.94||||5332.94|2133.18|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|5332.94||||5332.94||4053.03|1066.59
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]|5332.94||||5332.94|3679.73|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|5332.94||||5332.94|2666.47|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|5332.94||||5332.94|3679.73|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5332.94||||5332.94|3679.73|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|Self-pay|Self-pay|5332.94||||5332.94|1066.59|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|TML [1980]|TML [198000]|5332.94||||5332.94|3679.73|4053.03|1066.59
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]|5332.94||||5332.94|2075.58|4053.03|1066.59
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]|5332.94||||5332.94||4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNICARE [2040]|UNICARE [204000]|5332.94||||5332.94||4053.03|1066.59
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]|5332.94||||5332.94||4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WEB TPA [2115]|WEB TPA [211500]|5332.94||||5332.94|3679.73|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
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]|5332.94||||5332.94|0|4053.03|1066.59
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WORKER'S COMP [2125]|TML WC [212537]|5332.94||||5332.94||4053.03|1066.59
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.3||||10.3||7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMBETTER [2930]|AMBETTER [293000]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|ANDREWS CENTER BEHAVIORAL HEALTH [3950]|ANDREWS CENTER BEHAVIORAL HEALTH [395000]|10.3||||10.3|5.15|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS MEDICAID [1165]|BCBS MEDICAID [116504]|10.3||||10.3|4.01|7.83|2.06
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]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.3||||10.3|7.42|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.3||||10.3|5.15|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.3||||10.3|5.15|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS TRADITIONAL OF TEXAS [115503]|10.3||||10.3|7.83|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA - GREAT WEST [126009]|10.3||||10.3|7.11|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA PPO [126025]|10.3||||10.3|4.12|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|GOLDEN RULE [1445]|GOLDEN RULE MEDICARE SUPPLEMENT [144500]|10.3||||10.3||7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.3||||10.3|7.11|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTH FIRST UTHET EMPLOYEE PLAN [239502]|10.3||||10.3|5.15|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HUMANA COMMERCIAL [2140]|HUMANA COMMERCIAL [214001]|10.3||||10.3|7.11|7.83|2.06
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]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.3||||10.3|0|7.83|2.06
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]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.3||||10.3|7.11|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|Self-pay|Self-pay|10.3||||10.3|2.06|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|TML [1980]|TML [198000]|10.3||||10.3|7.11|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.3||||10.3|4.01|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.3||||10.3||7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNICARE [2040]|UNICARE [204000]|10.3||||10.3||7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.3||||10.3||7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WEB TPA [2115]|WEB TPA [211500]|10.3||||10.3|7.11|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.3||||10.3|0|7.83|2.06
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]|10.3||||10.3|0|7.83|2.06
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TML WC [212537]|10.3||||10.3||7.83|2.06